Dual Woven EndoBridge deployment and neuroendoscopic hematoma evacuation for a ruptured multilobulated middle cerebral artery aneurysm: A case report

Background: Ruptured wide-necked or multi-lobulated intracranial aneurysms pose a challenge in the acute phase of subarachnoid hemorrhage (SAH), in which antiplatelet therapy is generally contraindicated. The Woven EndoBridge (WEB) device enables intrasaccular occlusion without requiring antiplatelet agents. However, the treatment of multilobulated aneurysms in this setting remains technically demanding. Case Description: An octogenarian patient presented with a poor-grade SAH due to a ruptured multilobulated aneurysm of the right middle cerebral artery (MCA) accompanied by intracerebral and subdural hematomas. Emergency endovascular treatment was performed using dual-horizontal WEB devices, each deployed in a separate lobule. Antiplatelet therapy was not administered. Subsequently, a neuroendoscopic hematoma evacuation was performed. Postoperative imaging confirmed complete exclusion of the aneurysm and resolution of the hematoma. The patient showed neurological improvement and was transferred for rehabilitation with acceptable clinical outcomes. Conclusion: This case illustrates the feasibility of combining dual WEB deployment with subsequent neuroendoscopic hematoma evacuation during the acute phase of SAH. This strategy may be a viable treatment option for ruptured multilobulated MCA aneurysms in older adults when conventional approaches are unsuitable.