Traumatic anterior cerebral artery aneurysms and management options in the endovascular era

•Traumatic ACA aneurysms can be difficult to diagnose owing to involvement of peripheral vasculature.•Surgery or coiling can be done safely in the management of ACA aneurysms.•Parent artery preservation should be the goal of any therapy.•High index of suspicion may diagnose such aneurysms early and prevent a catastrophic SAH.

Traumatic anterior cerebral artery (ACA) pseudoaneurysms are a challenge to manage. Difficult diagnosis, delayed presentation and catastrophic outcomes contribute to the overall prognosis of traumatic intracranial aneurysms. Clipping or coiling of the aneurysm and/or parent vessel occlusion are the treatment options. However, surgery and coiling both may be difficult due to limited access and the need for parent vessel preservation. Rarely, these aneurysms must be managed conservatively. We present four patients with traumatic ACA aneurysms admitted to our center in the last 10 months. Three patients had pseudoaneurysms of the distal ACA and one had an aneurysm arising from a cortical branch of the ACA. Their clinical presentations and management, along with outcomes, are discussed as well as the dilemmas associated with them. Three patients were managed by clipping and coiling while one was managed conservatively. The diagnosis was made relatively early in three patients while delayed subarachnoid hemorrhage led to diagnosis in the fourth. Although the overall prognosis remains grim, with high mortality and morbidity rates, both microsurgical and interventional management of these traumatic aneurysms may be useful, if detected early before rupture. Expectant management and surveillance may be required in a select group of patients.