Angiographically progressive change of traumatic pseudoaneurysm arising from the middle meningeal artery

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.

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.

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

BACKGROUND

Traumatic pseudoaneurysm of the middle meningeal artery (PMMA) is rare. Its rupture is associated with high mortality, so an early diagnosis is recommended for this risky condition. In the absence of a specific guideline, computed tomography (CT), digital subtraction angiography, and CT angiography (CTA) are proposed for its diagnosis. CTA is the technique of choice even if it is almost never performed, especially in mild head injury. We report a rare case of a delayed rupture of PMMA, analyzed from a forensic point of view.

METHODS

Fifteen days after mild blunt head trauma, characterized by temporal fracture and a small hemorrhage near the rim, a wide intraparenchymal hemorrhage (IPH) occurred. The onset of IPH was marked by neurologic deterioration and arm paralysis. Immediate head CT showed IPH, and CTA showed PMMA. Prompt surgery could not help patient survival. The goal of autopsy was to formulate the cause of death and to individuate potential medical negligence.

RESULTS

In the literature, 16 cases of 54 are related to PMMA (26%) and are associated with IPH. IPH can be acute or delayed. Eight cases of acute IPH and 8 cases of delayed IPH (including our case), both coexisting with PMMA, are described. The literature review showed that the association of temporal rim fracture and a small hemorrhage nearby is highly predictive of PMMA formation.

CONCLUSIONS

Therefore, in the presence of these 2 risk factors after heat trauma, CTA is strongly suggested.

Management of Unruptured Traumatic Middle Meningeal Artery Pseudoaneurysms through Onyx Embolization

Traumatic pseudoaneurysms of the middle meningeal artery (MMA) represent less than 1% of all intracranial aneurysms, and occur mostly in association with temporal bone fractures following head trauma. Given the unknown natural history, it is unclear whether they should be treated. We present two cases of MMA pseudoaneurysms discovered during trauma workups. The first patient is a 44-year-old male with severe traumatic brain injury (TBI) following a motor vehicle accident. The patient was found to have two right-sided middle meningeal artery pseudoaneurysms that were treated successfully with Onyx® (Medtronic, Minneapolis, MN) embolization. The second patient is a 56-year-old male that sustained a severe TBI and skull fracture following a motorcycle collision. Angiography demonstrated an unruptured right MMA aneurysm, which was also treated successfully with Onyx embolization. MMA pseudoaneurysms occur rarely in the setting of severe traumatic injuries. In select patients, treatment by an experienced neuro-interventionalist can prevent highly morbid future intracranial hemorrhages with minimal risk of complications.