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.