Background <p>Ruptured intracranial aneurysm (RIA) is the leading cause of spontaneous subarachnoid hemorrhage (SAH), with a high disability and mortality rate. This case details a patient with a ruptured aneurysm at the middle cerebral artery (MCA) bifurcation accompanied with seriously cerebral herniation successfully treated with the Woven EndoBridge (WEB) device placement via a distal transradial access.</p> Case presentation <p>A 51-year-old male Asian patient was admitted to Zhuhai People's Hospital due to a 6-hour consciousness impairment and left limb weakness. An emergency cranial computed tomography (CT) and computed tomography angiography (CTA) showed the patient had a ruptured aneurysm at the MCA bifurcation accompanied by a cerebral herniation. The Hunt–Hess grade was Ⅲ, the Glasgow Coma Scale (GCS) score was 9, and the National Institutes of Health Stroke Scale (NIHSS) score was 14. After obtaining informed consent from the family and discussing treatment options, the patient was successfully treated with the endovascular treatment by the WEB device placement via a distal transradial access. Intraoperative angiography showed complete deployment of the WEB in good position with aneurysm occlusion, achieving a Woven EndoBridge occlusion scale (WOS) grade of B. Subsequently, intracranial hematoma evacuation and decompressive craniectomy were immediately performed. At discharge, the patient scored 4 on the modified Rankin Scale (mRS). Six months and eighteen postoperatively, the patient returned for a follow-up examination with an mRS score of 1. Follow-up cranial CT showed absorption of the hematoma, and cerebral angiography confirmed complete aneurysm occlusion with a WOS grade of A.</p> Conclusions <p>This case demonstrates the technical feasibility of a combined strategy employing initial WEB embolization via distal transradial access followed by surgical decompression, for the management of a single patient with a critical ruptured middle cerebral artery aneurysm and cerebral herniation.</p>