Treatment Algorithm for Concomitant Parasellar Meningiomas and Proximal Intracranial ICA Aneurysms in the Flow Diversion Era

Abstract Concomitant parasellar meningiomas and aneurysms of the proximal intracranial internal carotid artery (ICA) represent a rare but complex neurosurgical challenge. Treatment sequencing remains a subject of ongoing debate, given the close anatomical proximity of these lesions to critical neurovascular structures and the need to carefully balance tumor resection with either microsurgical or endovascular aneurysm management. A structured treatment algorithm integrating aneurysm rupture status, anatomical accessibility, and symptomatology was applied to three patients with concomitant parasellar meningiomas and proximal intracranial ICA aneurysms. All cases were managed by the senior author between October 2021 and October 2024. Clinical, radiological, and surgical data were collected and reviewed retrospectively. Three patients with concurrent parasellar meningioma and ipsilateral ICA aneurysm were identified among 67 patients who underwent meningioma resection during the study period. Treatment strategies included tumor resection and observation of the aneurysm, staged endovascular aneurysm treatment followed by tumor resection, and initial tumor resection with delayed flow diversion. Treatment decisions were individualized based on aneurysm morphology, rupture risk, and symptom origin. All patients achieved favorable clinical outcomes without neurological decline. A tailored, stepwise algorithm allows for safe and effective management of concomitant parasellar meningiomas and proximal intracranial ICA aneurysms. Simultaneous treatment is feasible in select cases, though a staged approach remains the preferred strategy in most situations. Endovascular therapy, particularly flow diversion, broadens the treatment landscape when microsurgical clipping is not safely achievable.