Introduction Persistent stapedial artery (PSA) is a rare vascular anatomical variant first identified as early as 1836 with an estimated prevalence of 0.02 to 0.5% in the general population (1). Most often asymptomatic, a PSA encountered during surgery presents significant risks including serious intra-operative bleeding, obstruction of anatomical landmarks and potential for neurological deficits. Clinical Case A 76 year old male presented with significant communication difficulties following an apparent bilateral sudden sensorineural hearing loss four months earlier. Audiological assessment confirmed a severe to profound hearing loss bilaterally with the patient undergoing pre-operative high resolution computed tomography (HRCT) to assess anatomical structure of the middle and inner ear for candidacy and surgical planning. Intra-operatively within the middle ear, a mucosa cover and pulsatile cord like structure was encountered obscuring the round window niche. Retrospective review of pre-operative imaging showed findings consistent with a PSA. Successful implantation was achieved via cochleostomy technique with complete insertion. Post-operative course was unremarkable with excellent speech discrimination outcomes two months post operatively. Conclusion To our knowledge there has been four previously reported cases of successful cochlear implantation in the presence of a PSA. Techniques included three round window insertions and one cochleostomy technique. With increasing rates of cochlear implantation globally, pre-operative review of radiological features of PSA may facilitate improved cochlear implantation counselling and surgical planning. It may also aid in decision making for implantation in cases of unilateral PSA evident radiologically prior to surgery. References 1.LoVerde Z, Shlapak D, Benson J, Carlson M, Lane J. The many faces of persistent stapedial artery: CT findings and embryologic explanations. Am J Neuroradiol. 2021;42(1):160–6.