Persistent primitive olfactory artery-associated aneurysms: diagnose the vessel before treating the aneurysm.

Persistent primitive olfactory artery (PPOA)-associated aneurysms are rare lesions in which treatment risk is determined not only by aneurysm morphology, but also by the anomalous parent vessel and its distal territory. These lesions should therefore be approached as anatomy-defined aneurysms rather than ordinary anterior cerebral artery aneurysms in an unusual location. Based on the available literature, PPOA-associated lesions most often arise at the hairpin turn or A1-PPOA origin, where abrupt curvature, branching, and parent-vessel dependence may influence treatment selection. We propose a practical anatomy-led framework that begins with recognition of the PPOA, followed by assessment of rupture status, lesion certainty, morphology, distal-territory dependence, and feasibility of parent-vessel preservation or reconstruction. Until stronger evidence is available, management should remain individualized, anatomy-led, and supported by long-term vascular surveillance.