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.