Delayed Intracerebral Hemorrhage After Pseudoaneurysm of Middle Meningeal Artery Rupture: Case Report, Literature Review, and Forensic Issues

Traumatic middle meningeal artery aneurysm: a case report

INTRODUCTION

Traumatic intracranial aneurysms are rare, making up about 1% of all intracranial aneurysms. They can happen due to direct injury or blunt force, with the middle cerebral artery being the most frequent site. The middle meningeal artery (MMA) is the main artery that supplies the cranial dura mater, and, because of its location, is susceptible to damage after trauma. This article reported an unusual case of giant post-traumatic MMA pseudoaneurysm.

CASE

A 45 year-old man was referred to our department with a history of craniectomy. He complained of non-specific headache, but neurological examination was normal. A follow-up brain CT scan identified a right temporal fossa hyperdense mass. Digital subtraction angiography diagnosed a traumatic MMA aneurysm. The patient was treated with preoperative aneurysm embolization and surgical resection.

DISCUSSION

Traumatic MMA aneurysm is a rare presentation after head trauma. It can manifest as epidural hematoma, subdural hematoma or intraparenchymal hematoma, and sometimes resembles the present case, which was discovered incidentally.

CONCLUSION

Pseudoaneurysm is a rare complication of MMA trauma, with late presentation. It should be considered in patients with history of traumatic brain injury and temporal fossa extra-axial mass lesion with vascular characteristics.

Predictors of Middle Meningeal Artery-Related Vascular Diseases Associated with Blunt Head Trauma

OBJECTIVE

Traumatic middle meningeal artery (MMA)-middle meningeal vein (MMV) fistula (MMA-MMV fistula) and MMA pseudoaneurysm are the 2 main MMA-related vascular diseases occurring after blunt head trauma. These are rare but known causes of delayed intracranial hemorrhage. This study investigated predictors that may aid in the diagnosis of these diseases.

METHODS

In our department, screening digital subtraction angiography (DSA) is performed for patients with blunt head trauma accompanied by intracranial hemorrhage and skull or facial bone fracture. This study included 87 patients who underwent screening DSA without craniotomy from January 2019 to June 2023. The patients' clinical characteristics were retrospectively collected from the database. Statistical analysis was performed to examine the associations of various evaluation items with MMA-related vascular diseases.

RESULTS

The first DSA examination revealed 34 MMA-MMV fistulas and 1 MMA pseudoaneurysm. The second follow-up DSA examination revealed 13 MMA-MMV fistulas and four MMA pseudoaneurysms. Temporal/parietal bone fracture (odds ratio, 5.33; P = 0.0005; 95% confidence interval, 1.95-14.60) was significantly associated with MMA-related vascular diseases. Endovascular treatments were performed in 9 patients. All procedures were successfully completed without complications; no delayed bleeding was observed.

CONCLUSIONS

Temporal/parietal bone fracture in patients with blunt head trauma is a likely predictor of MMA-related vascular diseases. When initial head computed tomography reveals this pathology, we recommend careful imaging follow-up (e.g., DSA) and treatment as needed, while considering the possibility of MMA-related vascular diseases.

Post-traumatic Middle Meningeal Artery Pseudoaneurysm Treated With Endovascular Coil Embolization

Pseudoaneurysms of the middle meningeal artery are rare events following head trauma. Given the potential for significant morbidity and mortality associated with pseudoaneurysm rupture, it is recommended that they be treated early. Endovascular embolization is a viable alternative to open surgical intervention. Here, we describe a case of an incidentally found middle meningeal artery pseudoaneurysm in a patient with a carotid-cavernous fistula after head injury. The pseudoaneurysm was treated with endovascular coil embolization.

Combining Endovascular Coiling and Open Evacuation for a Delayed-Onset Ruptured Post-traumatic Pseudoaneurysm of the Distal Paracentral Pericallosal Artery Branch

Cerebrovascular pseudoaneurysm development and rupture is a rare, delayed sequelae of trauma. We present a case of a female patient in her sixties who presented after a fall without evidence of vascular injury on imaging. However, after one week, repeat imaging due to an abrupt change in mental status revealed a ruptured pseudoaneurysm, which was treated with a combination of coil embolization and open surgical evacuation of associated intracranial hematoma. This case illustrates the importance of continued surveillance beyond the acute traumatic period to identify late-onset complications in trauma patients requiring emergent treatment.

Unusual Intracerebral Hemorrhage Secondary to Delayed Posttraumatic Middle Meningeal Artery Pseudoaneurysm, Successfully Treated by Endovascular N-Butyl Cyanoacrylate Embolization

Pseudoaneurysm of the middle meningeal artery, presenting as a delayed sequela of trauma, being a rare entity, may sometimes present as an acute intraparenchymal hemorrhage, with a risk of rerupture and mortality. The optimal management in acute settings remains undetermined. We, hereby, report a case of elderly gentleman with a history of a road traffic accident. Noncontrast computed tomography (NCCT) brain was reported to have left parietal hemorrhagic contusion without any mass effect. The patient was managed conservatively without any major neurological deficits. After 7 months, the patient presented with severe headache, altered sensorium, and right hemiparesis. NCCT brain showed acute left thalamocapsular hemorrhage with minimal subarachnoid hemorrhage with associated mass effect and impending herniation. Considering the fall in patient's baseline Glasgow comma scale response, pupillary asymmetry, and CT findings, immediate decompression and hematoma evacuation were advised. In view of atypical morphology, the patient was planned for urgent digital subtraction angiography prior to the surgery to rule out the ruptured aneurysm or pial arterio-venous fistula. Selective angiography of the left external carotid artery demonstrated a dissecting pseudoaneurysm feeding from the middle meningeal artery (MMA), which was embolized using n-butyl cyanoacrylate (NBCA). Postprocedure DynaCT revealed the left temporal bone fracture, indicating this pseudoaneurysm to be most likely posttraumatic delayed sequelae. Postembolization, the patient underwent surgical decompression and excision of hematoma. Patient's neurological status gradually improved and was discharged with the minimal deficit. Our case highlights the importance of awareness of the posttraumatic MMA pseudoaneurysm as an uncommon but treatable entity, which can be easily diagnosed using cerebral angiography and amenable to safe and effective endovascular embolization using NBCA.

Delayed Spontaneous Resolution of a Traumatic Middle Meningeal Artery Pseudoaneurysm

Patient: Male, 42-year-old

Final Diagnosis: Middle meningeal artery pseudoaneurysm

Symptoms: Migraine

Medication:—

Clinical Procedure: —

Specialty: Radiology

Surgical resection of a large posttraumatic middle meningeal artery pseudoaneurysm with associated epidural hematoma

Background:

Middle meningeal artery (MMA) pseudoaneurysms are rare but can occur secondary to trauma with an associated skull fracture and can present with a variety of hemorrhage patterns. Epidural, subdural, subarachnoid, and intraparenchymal hematomas have all been reported. Given the wide range of clinical presentations and radiographic findings, multiple treatment strategies have been employed, including surgical removal, endovascular intervention, and conservative treatment. MMA pseudoaneurysms typically range from 2 to 5 mm in size and have been shown to have unpredictable growth patterns.

Case Description:

A 54-year-old male identifying as a Jehovah’s Witness presented after a fall and was found to have an epidural hematoma with an accompanying temporal bone fracture. Imaging demonstrated a traumatic pseudoaneurysm of the MMA. Given the patient’s religious preferences, the emphasis was made during surgical planning for the minimization of blood loss. The epidural hematoma was evacuated, and the MMA pseudoaneurysm was directly visualized and surgically excised after ligation of its tributaries. The patient tolerated the procedure well without significant blood loss and made a complete neurological recovery.

Conclusion:

A well-circumscribed hypodensity on CT within a surrounding hyperintense collection should raise suspicion of MMA pseudoaneurysm in the setting of overlying temporal bone fracture as supported by previous imaging findings of large MMA pseudoaneurysms. The early detection of MMA pseudoaneurysm is imperative, as the presence may dictate more urgent intervention and changes in operative technique. Although not much is known about the nature and progression of these lesions, surgical excision has remained a safe, reliable method of treatment.

Pseudoaneurysm Resulting in Rebleeding After Evacuation of Spontaneous Intracerebral Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is a devastating cerebrovascular disease with high morbidity and mortality. Branching pattern of the lenticulostriate arteries from the middle cerebral artery makes them susceptible to formation of microaneurysms, which have been implicated in hypertensive ICH. Recurrence of hematoma due to delayed development of pseudoaneurysm after initial surgical evacuation is uncommon.

CASE DESCRIPTION

Our patient is a 61-year-old gentleman who underwent primary evacuation of a spontaneous right-sided ICH. The initial vascular imaging was unremarkable for any underlying vascular malformation. After initial neurologic recovery, the patient developed another rebleeding in the hematoma cavity nearly 10 days after presentation. A formal angiogram showed the presence of a pseudoaneurysm that was treated via endovascular means.

CONCLUSIONS

The rates of rebleeding have ranged from 10%-40% in various studies and have been directly correlated with mortality. Since follow-up with angiograms are not a usual practice in spontaneous ICH management, such as pseudoaneurysmal rebleeds could go undiagnosed. This case report reinforces the need for a thorough angiographic evaluation in the event of a deviation from expected clinical course, rebleeding not in concordance with intraoperative findings and significantly delayed hematoma recurrence.

N-butyl cyanoacrylate embolization of a traumatic pseudoaneurysm and arteriovenous fistula of the middle meningeal artery

We report a case of combined traumatic pseudoaneurysm and arteriovenous fistula of the middle meningeal artery, which presented clinically 1 year after initial head trauma. A 39-year-old male presented with seizure activity after a closed head injury from a fall. He was hospitalized for multiple intraparenchymal hemorrhages and ultimately discharged 2 weeks later without neurologic deficits. One year later, he presented with a new right anterior temporal intraparenchymal hemorrhage after a syncopal event. Selective angiography of the right external carotid artery demonstrated a chronic appearing traumatic laceration of the proximal middle meningeal artery with a 6 × 10 mm pseudoaneurysm and a single fistula with venous varix draining into the lateral pterygoid veins. The pseudoaneurysm and arteriovenous fistula were successfully embolized with n-butyl cyanoacrylate.

Intracranial Hemorrhage Secondary to a Delayed Cerebral Pseudoaneurysm Rupture 18 Years after Cranial Trauma

We report the case of a 38-year-old male with a previous history of severe cranial trauma and subsequent large subdural and subarachnoid hemorrhage on whom an emergent hematoma evacuation was performed with a good outcome and follow-up. Despite a good clinical evolution, the patient experienced a further intracranial hematoma 18 years after the trauma, with severe aphasia and mild right hemiparesis. After complete etiological study, two cranial pseudoaneurysms were observed in the cerebral angiography. Endovascular treatment was successfully completed, achieving full embolization without complications. No rebleeding was detected during follow-up. The patient had a good clinical outcome at 3 months and achieved complete recovery. Cranial pseudoaneurysm rupture is a rare cause of intracerebral hemorrhage, especially if the trauma occurs years before the bleeding.

Onyx™ embolization for an angiographically progressive traumatic pseudoaneurysm of the middle meningeal artery: A case report and literature review

Traumatic pseudoaneurysm of the middle meningeal artery (MMA) is a rare entity that is typically associated with a high risk of rupture and mortality. Only few such cases of pseudoaneurysms have been reported in the medical literature and therefore, the optimal management of this condition remains undetermined. The present study reported on a female patient (age, 20 years) with angiographically progressive pseudoaneurysm of the MMA after head injury. The pseudoaneurysm was successfully embolized with the liquid, non-adhesive embolic agent Onyx™. The mechanism of formation of traumatic pseudoaneurysms, their imaging characteristics and the optimal treatment plan were discussed.