Evolution of Diagnosis and Management of Traumatic Intracranial Aneurysms Secondary to Penetrating Brain Injury

Traumatic intracranial aneurysms (TICAs) secondary to penetrating traumatic brain injuries (PTBIs) including gunshot wounds and shell fragments carry a significant risk of rupture, intracerebral hematoma, neurological injury, and death. Although these lesions were previously thought to arise in a delayed fashion, TICAs have been increasingly reported immediately after PTBI. Early detection and endovascular therapies have contributed to a significant evolution in their management. Here, we review and present reported TICAs in the literature spanning both civilian and military contexts. Lesions are analyzed by morphology, location, management strategies, and outcomes.

Case series/reports published between 1940 and 2025 were considered. Injury mechanism, arterial location, diagnostic imaging modality, time to diagnosis, treatment, and outcome data were collected. Only full texts were considered in the final analysis.

A total of 250 traumatic intracranial pseudoaneurysms in 227 patients met inclusion criteria for this study. The most common vessel distribution was the middle cerebral artery (MCA, n = 98), followed by the anterior cerebral artery (n = 68) and internal carotid artery (ICA n = 48, of which 13 were in the cavernous ICA). Historically, TICAs were detected in a delayed fashion using conventional angiography (104 patients, 113 TICAs). In recent years, early detection of TICAs has been facilitated by CT angiography (CTA; 52 patients and 64 TICAs) and digital subtraction angiography (DSA; 52 patients and 53 TICAs). Endovascular surgery and open approaches complement each other in the obliteration of TICAs, with a significant increase in the use of the former during the last three decades.

TICAs are complex lesions secondary to PTBIs. Detection, management strategies, and outcomes have evolved over the last several decades. Early detection using CTA and DSA has significantly increased the incidence of these lesions in the acute phase. Vigilant monitoring and delayed follow-up imaging remain essential components of modern management given the risk of delayed aneurysm formation, growth, and recanalization.