One-stage dual-approach clipping for concomitant ipsilateral true and junctional posterior communicating artery aneurysms

Background: True posterior communicating artery (PCoA) aneurysms are rare and technically demanding because of their deep location and close association with perforating arteries. When concomitant ipsilateral internal carotid artery (ICA)–PCoA and true PCoA aneurysms are present, a single anterior surgical corridor may not provide sufficient visualization of the posterior PCoA complex. Methods: We describe a one-stage combined microsurgical strategy that integrates pterional and subtemporal approaches to achieve complementary visualization of the PCoA cistern. The anatomical rationale, operative sequence, and indications are presented and supported by a representative case of perforator adherence to the aneurysm dome. Results: The pterional approach enabled secure proximal control and treatment of the ICA–PCoA aneurysm, whereas the subtemporal approach provided direct lateral and posterior views of the true PCoA aneurysm and its perforators. This combined strategy allowed perforator-preserving clip application and complete obliteration of the aneurysm without ischemic or venous complications. Conclusion: In selected cases of concomitant ipsilateral ICA–PCoA and true PCoA aneurysms, a one-stage combined pterional and subtemporal approach overcomes the visual limitations of the anterior corridors alone and enables safe, perforator-preserving microsurgical treatment.