Endovascular parent artery occlusion as salvage therapy for a pseudoaneurysm of an accessory middle cerebral artery trunk with ipsilateral internal carotid artery

Endovascular parent artery occlusion (PAO) as salvage therapy for a pseudoaneurysm of an accessory middle cerebral artery (AMCA) trunk remains exceptionally rare in documented literature. Here, such a case treated by this innovative approach is reported. A 72-year-old male patient presented with a comatose state persisting for 6 hours. On neurological examination, he exhibited grade II muscle strength in both upper and lower extremities, with a Hunt-Hess scale score of grade III. Computed tomography (CT) revealed extensive intracranial hemorrhage. Digital subtraction angiography (DSA) revealed occlusion of the left internal carotid artery and a pseudoaneurysm of the left AMCA trunk. After selective catheterization of the accessory AMCA trunk, Onyx injection resulted in complete obliteration of the pseudoaneurysm and parent artery. DSA confirmed adequate collateral circulation in the left MCA territory. Postoperatively, the patient returned to preoperative baseline status but subsequently developed left upper limb paralysis. CT revealed new infarction in the left AMCA region. One week postoperatively, the patient was transferred to a local hospital for rehabilitation. At 1-month follow-up, he remained comatose despite rehabilitation. Therefore, for the rare AMCA trunk pseudoaneurysm with unfavorable clinical conditions or limited treatment options, PAO may serve as a salvage therapy, albeit requiring meticulous evaluation of potential infarction risks. Nevertheless, its applicability is constrained by limited generalizability.