Combined Microsurgical and Endovascular Treatment Strategy for a Persistent Superior Hypophyseal Artery Aneurysm with an Infraoptic Anterior Cerebral Artery Origin: Anatomic Considerations and Multimodality Management.

Superior hypophyseal artery aneurysms are occasionally associated with infraoptic anterior cerebral artery (ACA) variants, characterized by the A1 segment coursing beneath the optic nerve.1,2 A 69-year-old woman presented with an 8-mm right superior hypophyseal artery aneurysm, and subsequent angiography demonstrated a Wong type I infraoptic ACA, resulting in a dual arterial supply to the aneurysm.3 Because of this anatomy, dual overlapping Pipeline Flex Embolization Device with Shield Technology (PED Shield; Medtronic, Irvine, California, USA) flow diverters were deployed. However, 1-year follow-up demonstrated persistent aneurysm flowing from continued infraoptic ACA inflow. Microsurgical clipping via supraorbital eyebrow craniotomy was performed, placing 2 mini-clips at the aneurysm-infraoptic ACA junction to eliminate anterograde filling while preserving retrograde perfusion. Complete exclusion with normal A1 patency was confirmed with intraoperative indocyanine green angiography, fluorescein angiography, and formal cerebral angiography. Six-month imaging demonstrated persistent occlusion. Infraoptic ACA variants resulting in dual blood supply may necessitate combined embolization and flow diversion or microsurgical approaches when flow diversion alone proves inadequate. Institutional review board approval was obtained, and written informed consent was obtained from the patient for publication of this case video and accompanying images.