Surgical repair of lacerated anterior cerebral artery presented with massive intracerebral hemorrhage.

OBJECTIVE AND IMPORTANCE: Traumatic intracranial aneurysms present diagnostic and therapeutic challenges. Owing to their fragile nature, endovascular intervention has become the first-line treatment; however, direct surgery has an advantage in certain cases. CLINICAL PRESENTATION: A 34-year-old man in coma was admitted after a motor vehicle accident. Brain computed tomographic scans revealed deep bifrontal, left intraventricular, and subarachnoid hemorrhages. Three-dimensional computed tomographic angiography and digital subtraction angiography revealed an aneurysm arising from the left pericallosal artery. INTERVENTION: A massive intracerebral hematoma prompted us to perform emergency surgical intervention. We immediately removed the hematoma and extirpated the aneurysm. After hematoma evacuation via the interhemispheric approach, a pulsating red sphere projecting from the pericallosal artery, with no obvious solid wall or neck, was encountered. While retracting the frontal lobe, it suddenly ruptured. Under temporary trapping of the parent artery, the point of bleeding was identified. No aneurysm wall or fibrous tissue was present, whereas a 1.5-mm laceration was observed at the pericallosal artery close to its branching point. The laceration was sutured with 10-0 nylon. Postoperative digital subtraction angiography confirmed patency of the pericallosal artery. CONCLUSIONS: Although recent technologic advances of intravascular surgery have enabled successful treatment of traumatic pseudoaneurysms, open surgical intervention still has some advantages of providing definitive hemostasis, allowing for parent artery reconstruction, and facilitating mass reduction. The case in the current study was quite unusual in that angiographic aneurysm had disrupted easily, leaving arterial laceration. This finding implies the probability of unavoidable parent artery occlusion when endovascular treatment is applied.