- Department of Neurosurgery, Kumamoto City Hospital, Kumamoto, Japan
- Department of Neurosurgery, Kumamoto Red Cross Hospital, Kumamoto, Japan
- Department of Pathology, Kumamoto Red Cross Hospital, Kumamoto, Japan
- Department of Neurosurgery, Kumamoto University, Kumamoto, Japan
Department of Neurosurgery, Kumamoto University, Kumamoto, Japan
DOI:10.4103/2152-7806.179586Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Takemoto Y, Hasegawa S, Nagamine M, Kasamo D, Matsumoto J, Miura M, Kuratsu J. A spontaneous superficial temporal artery pseudoaneurysm possibly related to atherosclerosis: Case report and review of literature. Surg Neurol Int 01-Apr-2016;7:
How to cite this URL: Takemoto Y, Hasegawa S, Nagamine M, Kasamo D, Matsumoto J, Miura M, Kuratsu J. A spontaneous superficial temporal artery pseudoaneurysm possibly related to atherosclerosis: Case report and review of literature. Surg Neurol Int 01-Apr-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/a-spontaneous-superficial-temporal-artery-pseudoaneurysm-possibly-related-to-atherosclerosis-case-report-and-review-of-literature/
Background:Spontaneous superficial temporal artery (STA) pseudoaneurysms are very rare; only four cases, including ours, have been reported to date. Therefore, the cause of them has not been studied.
Case Description:A 57-year-old woman was admitted to our hospital with a pulsatile mass in the left preauricular region. Her medical history included hypertension, dyslipidemia, and angina pectoris. She denied a history of head injury or minor head trauma. Three-dimensional computed tomography angiography showed a well-enhanced saccular aneurysm on the main trunk of the STA. To prevent rupture it was removed surgically. The histological diagnosis was pseudoaneurysm with atherosclerosis. By the 2nd postoperative day, she had completely recovered and was discharged home. There has been no relapse.
Conclusions:As all four documented patients were at high risk for atherosclerosis, we posit that a causal factor was weakening of the arterial wall due to atherosclerosis and chronic pressure on the STA from anatomical structures. Here, we present histological evidence to support this hypothesis.
Keywords: Pseudoaneurysm, spontaneous, superficial temporal artery
The first case report of a superficial temporal artery (STA) aneurysm was published in 1740; subsequently, about 400 additional cases have been reported.[
Presentation and clinical evaluation
This 57-year-old woman was referred to our hospital with a growing pulsatile mass in the left preauricular region. She had first noticed the gradually growing mass 5 years earlier. Her medical history included hypertension (HT), dyslipidemia (DL), and angina pectoris. She was treated with oral calcium- and angiotensin II receptor blockers. She had no recollection of head injury or minor head trauma.
Physical examination disclosed no neurological deficits. There was a 13 mm × 10 mm pulsatile mass in the left preauricular region; it was painless but annoying. Three-dimensional computed tomography angiography showed a well-enhancing saccular aneurysm on the main trunk of the STA [
We were instructed her to manually compress the pseudoaneurysm (press a finger on the skin over the pulsatile area) for 30 min 3 times a day. However, it did not thrombosed. To prevent aneurysmal rupture we performed the surgical removal.
Pre- and intra-operative superficial temporal artery aneurysm imaging and figure. (a) Three-dimensional computed tomography angiogram showing an aneurysm on the main trunk of the superficial temporal artery and the preauricular region on the zygomatic arch. (b) Intraoperative photograph showing the superficial temporal artery aneurysm. There is a small distance between the feeding and the draining artery. (c) Lateral view of the cranial and superficial temporal artery schema showing that the main trunk of the superficial temporal artery crosses the zygomatic arch in the preauricular region, the site where the spontaneous superficial temporal artery pseudoaneurysm developed (arrow). The superficial temporal artery passes over the linea temporalis (white arrowhead) and includes its tip (black arrowhead)
With the patient under general anesthesia, we made a skin incision about 4 cm above the main trunk of the left STA. The aneurysm was saccular and located lateral to the zygomatic arch. There was a small distance between the feeding and draining vessels [
Several histologic sections were prepared from the surgically resected specimen. A cross-section of the aneurysm [
Histological features. (a) Low magnification of the lesion showing saccular dilation of the artery. The remnant of the internal elastic lamina is seen on the left (arrowheads). Victoria blue - H and E staining. (b) High magnification of the aneurysmal wall (encased by a rectangle in
The patient was discharged home on the 2nd postoperative day. Her condition continues to be good and at the last follow-up 12 months after the operation, there was no evidence of recurrence.
Although no universally accepted classification of STA aneurysms based on their etiology has been established, they have been classified as traumatic, iatrogenic, and spontaneous.[
Traumatic aneurysms include those that arise following blunt head trauma, vehicular accidents, stab and gunshot wounds, and sports-related injuries,[
Histologically, most traumatic STA aneurysms exhibit the features of pseudoaneurysms.[
Although Nii et al.[
Most traumatic aneurysms in the head arise on the STA due to its anatomical location.[
They suggested the congenital vulnerability of the arterial wall in this patient population, rather than atherosclerosis, as an important causal factor and the anatomic features of the preauricular region as a contributing factor. From a different perspective, this portion of the STA is not vulnerable to traumatic injury because it runs inside a line from the auricle to the zygomatic arch [
There are two specific sites on the STA that are vulnerable to trauma. One is its peripheral tract; the temporalis muscle is the only protective tissue between the STA and the outer table of the skull. The peripheral portion is particularly vulnerable to injuries due to the lack of protective temporal and frontal muscle tissues [
Other common findings in the four patients with spontaneous STA pseudoaneurysms were their demographics and medical history. All were middle-aged or older women with a history of HT and DL, putting them at high risk for atherosclerosis [
Based on our and previously reported observations in patients with spontaneous STA pseudoaneurysms, we suggest that atherosclerosis, which weakens the arterial wall, and chronic pressure on the STA from anatomical structures, play a role. To support our hypothesis, more case reports and series are needed to identify patient demographics devoid of bias as we cannot rule out the possibility that patients forgot minor trauma to the affected site.
To the best of our knowledge, this is the first report of the possible association between atherosclerosis and a spontaneous STA pseudoaneurysm. HT and DL must be treated to prevent cardiovascular events and to prevent spontaneous STA pseudoaneurysms, and physical stress on temporal areas must be avoided, especially in middle-aged and older women with risk factors for atherosclerosis.
Financial support and sponsorship
Conflicts of interest
All authors who are members of the Japan Neurosurgical Society (JNS) have registered online self-reported conflict of interest disclosure statement forms through the website for JNS members.
I would like to express my sincere gratitude to my supervisor, Prof. Junichi Kuratsu for providing me this precious study opportunity. I especially would like to express my deepest appreciation to my supervisor, Dr. Shu Hasegawa for his elaborated guidance, considerable encouragement, and invaluable discussion that make my research of great achievement and my study life unforgettable.
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