Managing Dual Intracranial Pathologies of a Ruptured ACA Aneurysm Presenting Concomitantly with a Large Anterior Fossa Meningioma: Illustrative Case with Operative Video and Literature Review.

Background Meningiomas and intracranial aneurysms rarely co-occur and even less frequently present with acute subarachnoid hemorrhage (SAH) from aneurysm rupture. When anatomically adjacent, management requires nuanced decision-making. Observations We present an illustrative case and video of a ruptured distal anterior cerebral artery dissecting aneurysm causing SAH and intraparenchymal hemorrhage in a patient with an anterior fossa meningioma encasing bilateral optic nerves. The aneurysm location, morphology, and potential involvement of an eloquent parent vessel branch deemed endovascular embolization and parent vessel sacrifice unsafe. The meningioma directly contacted the aneurysm and its parent artery, rendering pre-resection securement unfeasible. We performed a single-setting, open, frontotemporal craniotomy with early Sylvian fissure dissection for proximal control, followed by systematic tumor resection and microsurgical clipping of the A2 dissection. Gross total resection of the meningioma with clip ligation of the aneurysm and preservation of parent vessel/associated perforators was achieved. The patient returned to work 6 months postoperatively without persistent neurologic deficits. A narrative review of the literature on aneurysmal SAH associated with concomitant meningioma was conducted. Lessons This case highlights the intricacies of managing vascular and neuro-oncologic pathology presenting simultaneously in a patient in extremis, along with a literature review. The patient consented to the procedure and publication.