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Introduction Since the ISUIA paper was published, surgical clipping (SC) of aneurysms has gradually changed with coil embolization (CE).Aim of study To investigate the new insights of a combined pterional (PA) and interhemispheric approach (IHA) in patients with ruptured AcomA aneurysms deemed unfavorable for CE and inoperable using the single PA or IHA in this endovascular treatment (EVT) era.Method With a PA, the prechiasmatic cistern was then dissected and the AComA area was exposed along the ipsilateral dominant A1. The position of the patient was then changed and the IHA was easily approached, and the cerebral aneurysm was dissected along the A2 on both sides. The location and direction of the dominant A1, which had already been secured through the PA, were easily determined, allowing proximal control.Results 4 were male, and one was female; average age was 48 years old. Average aneurysm size was 6.7x5.4mm.The direction of the aneurysms was superior in 2 cases and posterior in 3 cases. The dominant A1 was on the left side in 4 cases and on the right side in one case. There were 3 cases of multi-lobular aneurysms, one case of a high-lying aneurysm, and one case of a broad-necked aneurysm. Complete cerebral aneurysm clipping was confirmed in all cases by CT angiography. Three months after the procedure, one case developed normal pressure hydrocephalus.Conclusion For high-lying, large-sized, broad-necked, posterior-directed AComA aneurysms, the combined technique involving exposure of the aneurysm neck using the IHA and safer proximal anterior cerebral artery-A1 exposure using the PA may be reasonable.Conflict of Interest No