Combined endovascular embolization and decompressive craniectomy for microsurgical resection of giant ruptured distal anterior cerebral artery aneurysm.

Giant ruptured distal anterior cerebral artery aneurysms are rare, challenging pathologies that may require a combination of microsurgical and endovascular techniques for optimal treatment [1-9]. We describe the case of a female in her 40 s who presented with a Hunt-Hess 4, Fisher 4 subarachnoid hemorrhage from a multiply ruptured, giant distal anterior cerebral artery aneurysm. The patient underwent coil and n-BCA glue embolization of the aneurysm and its feeding A2 anterior cerebral artery. She subsequently underwent decompressive craniectomy, intracerebral hematoma evacuation, and microsurgical trapping and resection of the aneurysm. Postoperative imaging demonstrated no further aneurysm filling, complete hematoma evacuation, and good decompression. The technical considerations and literature for the combined treatment of large and giant ruptured aneurysms are reviewed. The case presentation, operative nuances, and postoperative course with imaging are reviewed with detailed anatomical diagrams to orient the viewer. The patient consented to the procedure and to the publication of her imaging.