- Department of Neurosurgery, St. Louis University, St. Louis, Missouri, USA
Jeroen Raymond Coppens
Department of Neurosurgery, St. Louis University, St. Louis, Missouri, USA
DOI:10.4103/2152-7806.173564Copyright: © 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: Marvin E, Laws LH, Coppens JR. Ruptured pseudoaneurysm of the middle meningeal artery presenting with a temporal lobe hematoma and a contralateral subdural hematoma. Surg Neurol Int 07-Jan-2016;7:
How to cite this URL: Marvin E, Laws LH, Coppens JR. Ruptured pseudoaneurysm of the middle meningeal artery presenting with a temporal lobe hematoma and a contralateral subdural hematoma. Surg Neurol Int 07-Jan-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/ruptured-pseudoaneurysm-of-the-middle-meningeal-artery-presenting-with-a-temporal-lobe-hematoma-and-a-contralateral-subdural-hematoma/
Background:Traumatic pseudoaneurysms of the middle meningeal artery (MMA) are rare, associated with skull fractures, and have a high mortality rate. When they rupture, MMA pseudoaneurysms frequently cause epidural hematomas and occasionally ipsilateral subdural or subarachnoid hemorrhage. Isolated intraparenchymal hemorrhage has also been reported.
Case Description:A 54-year-old female who suffered a loss of consciousness resulting in a fall presented with a Glasgow Coma Scale of 7t. Imaging demonstrated a right subdural hematoma (SDH) with midline shift, left skull fracture overlying the left MMA, and left temporal lobe intraparenchymal hematoma extending to the surface. The patient underwent a right craniectomy with evacuation of the SDH, and the preoperative computed tomographic angiography revealed abnormal dilation of the left MMA consistent with a pseudoaneurysm. The pseudoaneurysm was treated with endovascular treatment, and the intraparenchymal hematoma was treated conservatively. Her recovery was uneventful, and she received a cranioplasty 3 months after the decompression.
Conclusions:The presence of a fracture over the MMA and intraparenchymal hematoma should prompt suspicion for a traumatic pseudoaneurysm. Pseudoaneurysms of the MMA can cause catastrophic bleeding, and prompt treatment is necessary. Endovascular embolization is an effective method that decreases the hemorrhage risk of MMA pseudoaneurysms.
Keywords: Intraparenchymal hemorrhage, subdural hematoma, traumatic pseudoaneurysm
Traumatic pseudoaneurysms of the middle meningeal artery (MMA) are uncommon. They are often associated with skull fractures[
Fifty-four-year-old female transferred from an outside facility after a fall stairs secondary to an episode of loss of consciousness. She presented with a Glasgow Coma Scale of 7t. She was purposeful but not following commands or opening her eyes. Computed tomography (CT) demonstrated a right-sided 0.8 cm thick SDH, with 6 mm of the right-to-left shift, along with a left-sided temporal lobe IPH measuring 8 cm by 2 cm by 1.5 cm [
True aneurysms consist of a focal dilation of an artery that contains all normal layers of an arterial wall and an intact adventitia. In contrast, a pseudoaneurysm, also known as a false aneurysm, is usually the consequence of a vascular injury that results in disruption of all layers of the artery. The formation of a hematoma occurs on the outside of the arterial wall. Histologically, the wall of a pseudoaneurysm does not contain normal arterial wall structures, and the hematoma is usually contained by adventitia or surrounding perivascular soft tissue. Schulze first described traumatic MMA pseudoaneurysms in 1957,[
The most frequent presentation of an MMA pseudoaneurysm is an epidural hematoma, occurring in up to 70% of cases.[
There have been several case reports describing delayed hemorrhages and neurological deterioration related to pseudoaneurysm rupture in patients that had recovered from their initial head injury.[
Delayed presentation seems more common in the cases of IPH.[
Radiographic identification of a pseudoaneurysm of the meningeal vessels may be difficult. There often needs to be a high index of suspicion to diagnose an MMA pseudoaneurysm. Epidural hematomas, for example, rarely require angiographic evaluation because hematomas that are associated with MMA injuries requiring surgical evacuation can be easily treated at the time of surgery. However, arterial injury in patients with nonsurgical epidural hematomas and underlying skull fractures may be underestimated. Active contrast extravasation was found in 71%,[
Of reported ruptured MMA pseudoaneurysm, it is estimated that 10% present with an IPH.[
Because MMA pseudoaneurysms are rare, the prognosis and treatment guidelines are somewhat controversial. The risk of re-hemorrhage in a previously ruptured traumatic pseudoaneurysm is unknown, and these lesions are characteristically unpredictable. Case reports have described spontaneous resolution/thrombosis of MMA pseudoaneurysms[
Traumatic MMA pseudoaneurysms can be treated through surgical resection or by endovascular means. The most common treatment modality used is endovascular embolization with tissue adhesive or hydrogel agents,[
Despite the unknown natural history of traumatic pseudoaneurysms, the potential for catastrophic bleeding exists, and treatment must be considered when discovered. A high index of suspicion should be maintained in the presence of a fracture overlying the MMA with an underlying IPH. CTA may suffice for screening, but in case of high suspicion, angiography should be considered. Surgical ligation of the MMA can be performed easily if hematoma evacuation is necessitated, but endovascular embolization is a safe and effective method for eliminating the hemorrhage risk in the presence of an MMA pseudoaneurysm if it is felt that surgical decompression is not mandatory.
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