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.

Delayed Carotid Pseudoaneurysms from Iatrogenic Clival Meningeal Branches Avulsion: Recognition and Proposed Management

BACKGROUND

Carotid injury during anterior skull base approaches is promptly recognizable and mandates immediate treatment; likewise, development of pseudoaneurysms after such injuries is anticipated and managed.

METHODS

We report here on the delayed development of a pseudoaneurysm as the result of avulsion of clival meningeal arteries that manifests as unalarming intraoperative bleeding.

RESULTS AND CONCLUSIONS

The bleeding is brisk and arterial but easily controlled. Immediate postoperative angiography is negative, necessitating repeated angiography to depict the delayed formation. It is best treated by endovascular means that maintains patency of the carotid artery, calling for the development of a suitable device that obliterates the opening of the pseudoaneurysm while maintaining carotid flow that is deployable in the tortuous carotid artery.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus

PURPOSE

Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

METHODS

A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus.

RESULTS

The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms.

CONCLUSION

A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Traumatic middle meningeal artery aneurysm causing intracerebral hematoma: a case report and review of literature

BACKGROUND

Traumatic aneurysms of middle meningeal artery (MMA) are rare. Traumatic MMA aneurysms usually present with extradural hematomas, whereas intradural intraparenchymal hematomas are exceedingly rare.

CASE DISCUSSION

We report a 30-year-old man who presented 1 year after head injury with spontaneous right frontal intraparenchymal hematoma. Investigations revealed a MMA pseudoaneurysm, which was successfully treated surgically.

CONCLUSION

Traumatic MMA pseudoaneurysm producing intracerebral hematoma (ICH) is rare and can be listed as a cause of spontaneous acute ICH.

Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report

BACKGROUND

Blood clot evacuation through an osteoplastic craniotomy, a procedure requiring neurosurgical expertise and modern medical facilities, is the accepted method for treatment of a pure traumatic epidural haematoma following closed head injury. In certain emergency situations and/or in less sophisticated settings, however, use of this procedure may not be feasible. The present study was undertaken to ascertain whether placement of a burr hole and drainage under negative pressure constituted a rapid, effective and safe approach to manage patients with simple epidural haematomas.

METHODS

Thirteen patients suffering from a traumatic epidural haematoma were treated from January, 1999 to October, 2002. Twelve patients presented with skull fracture but no fracture was depressed. Placement of flexible tubes through a burr hole, followed by continuous suction under negative pressure, enabled aspiration of the clot and drainage of the cavity. In 8 cases, the procedure was performed under local anaesthesia with 2% Xylocaine and with intravenous sedation with propofol as needed. The operative procedure was accomplished within 30 min, and the drainage tube was left in place for 3-5 days. CT scans were performed daily from days 1 to 5.

RESULTS

In 11 of 13 cases, clots were evacuated successfully and patients regained consciousness within 2 hours. Recoveries occurred without significant sequelae. In the remaining 2 cases, the drainage tube was found to be obstructed by a blood clot such that the haematoma was unaffected. A traditional craniotomy was performed within 8-12 hours, and these 2 patients recovered consciousness within the subsequent 6 hours.

CONCLUSION

Burr hole evacuation followed by drainage under negative pressure is a safe and effective method for emergency management of a pure traumatic epidural haematoma. To assure safety patients given this procedure should be monitored by daily CT scans. Decompressive craniotomy should be performed if consciousness does not improve within several hours.

Spontaneous resolution of traumatic pseudoaneurysm of the middle meningeal artery

We describe a case of traumatic pseudoaneurysm of the middle meningeal artery in a patient after a head trauma. The aneurysm was found incidentally and resolved spontaneously without any intervention; this outcome suggests that middle meningeal artery aneurysm may not require treatment in all cases and can be followed conservatively with follow-up conventional angiography.

Management of Middle Meningeal and Superficial Temporal Artery Hemorrhage From Total Temporomandibular Joint Replacement Surgery With a Gelatin-Based Hemostatic Agent

Complications associated with temporomandibular joint (TMJ) replacement surgery may include injury to nerves, blood vessels, and otologic structures. Vascular injuries can be associated with trauma to the carotid artery and its terminal branches, the superficial temporal artery, and the internal maxillary artery. Suggested management to control hemorrhage has included uniand bipolar electrocautery, laser ablation, local anesthetics with vasoconstrictors, direct pressure, embolization, and ligation. In this case report, the iatrogenic injury to both the middle meningeal and superficial temporal arteries during total TMJ replacement surgery controlled by using a gelatin-based hemostatic agent is discussed.

Efficacy of endovascular surgery for the treatment of acute epidural hematomas

BACKGROUND AND PURPOSE

Recent advances in the equipment and technology for endovascular surgery have led to an increasing number of patients undergoing this procedure to treat various lesions. The purpose of this study was to investigate the efficacy of early-stage endovascular surgery to treat growing acute epidural hematomas (AEDHs).

METHODS

Over a period of 2.5 years, endovascular intervention was performed in nine patients with AEDHs, as shown by the extravasation of contrast medium and the recognition of growing hematomas on CT scans. Embolization was performed by using catheters superselectively advanced with a microguidewire until it reached the area just before the bleeding point.

RESULTS

In all nine cases, bleeding from the middle meningeal artery ceased immediately after treatment, and further surgical intervention was avoided. In three of five patients with additional lesions, surgical intervention was also conducted to treat an acute subdural hematoma (two patients) or a contusion hematoma (one patient); in two cases, these lesions were located on the contralateral side.

CONCLUSION

In patients with thin AEDHs in the early stage, angiography followed by endovascular intervention allows for conservative treatment. Notable clinical benefits can be achieved in patients with complicated, multiple lesions.

Traumatic middle meningeal artery pseudoaneurysm and subsequent fistula formation with the cavernous sinus: case report

BACKGROUND

A combination of pseudoaneurysm and arteriovenous fistula of the middle meningeal artery is rare. We describe a case of traumatic pseudoaneurysm of the middle meningeal artery, which subsequently formed a fistula with the cavernous sinus.

CASE DESCRIPTION

A 23-year-old man suffered from blunt head trauma and skull fractures. Sixteen days later, he suddenly experienced headache and a bruit was auscultated over the left ear. Three-dimensional computed tomographic angiography revealed dilatation of the left middle meningeal artery. The dilation proved to be a pseudoaneurysm on cerebral angiograms and it was also found to have formed a fistula with the cavernous sinus. Both lesions were successfully obliterated by endovascular embolization using microcoils.

CONCLUSION

Head injury may lead to asymptomatic pseudoaneurysm or dural arteriovenous fistula. Neurosurgeons should always bear in mind the possibility of such vascular injuries after blunt head trauma to prevent any hemorrhagic complications.

Traumatic lesions of the bilateral middle meningeal arteries--case report

A 44-year-old man presented with traumatic injuries of the bilateral middle meningeal arteries after a traffic accident. Neurological examination found left visual impairment due to left optic nerve injury. Computed tomography demonstrated a small amount of left epidural hemorrhage and bilateral skull fractures. Left external carotid angiography revealed a pseudoaneurysm of the left middle meningeal artery at the sphenoid ridge. Right external carotid angiography demonstrated a dural arteriovenous fistula fed by the right middle meningeal artery colocated with the right frontal convexity fracture. Transarterial embolization of the left middle meningeal artery pseudoaneurysm with four fibered platinum coils and transarterial embolization of the right dural arteriovenous fistula with poly(2-hydroxyethyl methacrylate-co-methyl methacrylate) were performed, resulting in complete obliteration of both lesions. Angiographic cure was obtained and the postoperative course was uneventful.

Traumatic false aneurysm of the middle meningeal artery causing an intracerebral hemorrhage: case report and literature review

BACKGROUND

Traumatic false aneurysms of the meningeal arteries are rare. We report an unusual case of an intracerebral hematoma caused by the rupture of a traumatic aneurysm of the middle meningeal artery.

CASE DESCRIPTION

A 64-year-old woman suffered a massive spontaneous intracerebral fronto-temporal hemorrhage. Cerebral angiogram revealed a pseudoaneurysm of the middle meningeal artery. At operation, a skull fracture was discovered in the vicinity of the aneurysm. The patient died the day after surgery.

CONCLUSION

Although rare, traumatic meningeal aneurysms should be considered as a possible cause of cerebral hematoma. Because of their potential morbidity and mortality, they must be detected and treated rapidly.

Bone defect associated with middle meningeal arteriovenous fistula treated by embolization--case report

A 57-year-old male presented with a frontal bone defect associated with a middle meningeal arteriovenous fistula (AVF) manifesting as headache. The patient had a history of head injury 19 years previously. Skull radiography and computed tomography demonstrated a left frontal bone defect. Left external carotid angiography demonstrated a middle meningeal AVF at the frontal region, at the same location as the bone defect. The AVF was fed by the bilateral middle meningeal and left deep temporal arteries, and drained by the superior sagittal and ipsilateral cavernous sinuses. The minor feeding artery, the left deep temporal artery, was embolized with polyvinyl alcohol particles, then 0.4 ml of a 1:3 mixture of n-butyl cyanoacrylate and lipiodol was injected from the left middle meningeal artery. Follow-up angiography 3 months after the embolization revealed complete obliteration of the fistula. The bone defect may have been caused by erosion of the frontal bone by the pulsating effect of the feeding and draining vessels of the fistula, or by inadequate nutrition to the bone tissue because of the arteriovenous shunt.

Iatrogenic arteriovenous fistula of the middle meningeal artery caused during embolization for meningioma--case report

A 73-year-old female developed middle meningeal arteriovenous fistula during embolization of a falx meningioma. The cause of this complication was thought to be perforation by the guide wire during catheterization at the sharp bend in the sphenoidal portion of the middle meningeal artery. Embolization of the fistula and the feeding artery to the meningioma with polyvinyl alcohol particles 250-355 microns size resulted in complete obliteration of the fistula. Computed tomography showed no epidural or subdural hematoma. Introduction of the microcatheter beyond the sharp bend in the middle meningeal artery should not be attempted to avoid the possibility of iatrogenic middle meningeal arteriovenous fistula.

Fatal intracranial hemorrhage following pediatric oral surgical procedure

Deaths during dental and oral surgical procedures may lead to litigation alleging malpractice. For this reason, and because of their sudden and unexpected nature, they often come to the attention of forensic pathologists. We review the clinical and anatomic findings of a 3-year-old boy who expired following an oral surgical procedure in the temporomandibular region. During the operation, perforation of the base of the skull occurred causing laceration of a branch of the middle meningeal artery and fatal subdural and epidural bleeding.

Posttraumatic pseudoaneurysm of the posterior meningeal artery associated with intraventricular hemorrhage

A 22-year-old man sustained a severe head injury and had a torn posterior meningeal artery that caused massive intraventricular hemorrhage. Traumatic pseudoaneurysm of the posterior meningeal artery should be considered in cases where intraventricular hemorrhage occurs in the presence of occipital bone fracture and contiguous epidural hematoma; vertebral angiography is of value in this regard.

Traumatic aneurysm of the middle meningeal artery presenting as delayed onset of acute subdural hematoma

A case is presented in which recurrence of acute subdural hematoma developed 29 days after head trauma. An emergency craniotomy was complicated by intraoperative profuse bleeding, which was caused by the rupture of a large false aneurysm of the middle meningeal artery. A pitfall in the surgical treatment of this rare lesion is discussed.

[Acute intracranial subdural hematoma of arterial origin after spinal anesthesia]

A case of an acute intracranial subdural haematoma occurring shortly after spinal anaesthesia is reported. A 67 year old poorly controlled hypertensive man, ASA II, underwent removal of a prostatic adenoma under spinal anaesthesia. He complained of postural headache on the third day after surgery. Unresponsive to the usual analgesics, his headache became severe, persistent and non postural on the fifth day. Twenty-four hours later, he suddenly presented with a left hemiplegia and became comatose. Computed axial tomography showed a large left-sided subdural haematoma, lying over the left hemisphere. During the immediate surgical removal, a pulsatile arterial bleeding originating from a small cortical artery was discovered, and stopped. The patient slowly recovered consciousness, but the hemiplegia remained. He finally died six months later of bronchopneumonia. The link between the haematoma and the spinal anaesthetic is not proven; the possible relationship between the two is discussed.

Bilateral extradural haematoma. Report of two cases

Two cases of bilateral extradural haematomas are reported. In case I, the haematomas developed simultaneously and were probably due to a tear in the sagittal sinus. In case II, the haematomas developed sequentially and were demonstrated by serial CT scannings after the removal of a seemingly unilateral lesion. A review of the literature points out the rarity of this condition which had been described even before the CT era, with varying clinical presentations and unusually poor surgical results. The advent of the CT has made the diagnosis of simultaneous bilateral extradural haematomas easier and is regarded as a significant factor in the improvement of the prognosis noted in recent reports. However, the possibility of delayed bilateral extradural haematomas escaping detection in the initial CT should be emphasized. This unusual clinical presentation stresses the value of a routine use of serial CT scannings in the acute phase of head injuries.

Traumatic false aneurysms of the middle meningeal artery

The authors report a rare case of traumatic false aneurysm of the middle meningeal artery associated with a delayed contralateral extradural hematoma. The extradural hematoma was evacuated, and the pseudoaneurysm was removed to avoid delayed rupture. The literature on traumatic aneurysms is reviewed.

Chronic epidural hematomas in childhood: increased recognition and non-surgical management

Three children with chronic intracranial epidural hematomas are described. The hematomas were identified by computed tomographic scanning two to eleven days after a head injury. Two of the children were managed non-surgically over a one month period, during which time they remained stable without deteriorating consciousness or development of focal neurologic signs, and with evidence of resorption of the hematomas on follow-up scans. One child, initially clinically stable, had surgical evacuation of her clot 17 days after the injury because of a recurrence of vomiting. The children with chronic epidural hematomas managed without neurosurgical intervention were normal on subsequent neurologic examinations.

Posttraumatic pseudoaneurysm of the extracranial middle meningeal artery

Pseudoaneurysms of the extracranial arterial tree are uncommon. To our knowledge, four cases of pseudoaneurysm of the internal maxillary artery have been reported, but there have been no reports of pseudoaneurysm of the extracranial segment of the middle meningeal artery. A 15-year-old girl, who suffered a gunshot wound in the right maxillary region, suffered a pseudoaneurysm of the proximal portion of the middle meningeal artery, as shown by carotid angiography six days after injury. The lesion was successfully treated with absorbable gelatin sponge embolization. Treatment of pseudoaneurysms reduces the risk of hemorrhage from subsequent rupture. Although these lesions are amenable to surgery, transvascular embolization or mechanical interruption appears to be simpler and equally effective.

Epidural hematoma of the newborn due to birth trauma

Epidural hematoma due to birth trauma is unusual. The presentation is similar to subdural hematoma in the newborn, but the results of subdural puncture may be normal. The CT scan is diagnostic and early surgical evacuation may be lifesaving.

[An interesting case of the traumatic middle meningeal arteriovenous fistula]

The authors reported an interesting case of the traumatic middle meningeal arteriovenous fistula which was caused by the minor head injury on the opposite side complicated with a subarachnoid hematoma, and was completely cured 35 days after head injury without any surgical intervention. A 75-year-old woman fell down after unconsciousness fit and hit her right head, then visited Matsuyama Shimin Hospital complaining of nausea, vomiting and severe left temporalgia. Neurologically, no other abnormalities were found. On plain skull roentogenograms, a linear fracture was noted on the right temporal bone, but not on the left side. A subarachnoid hematoma localized in the left Sylvian fissure was identified on plain computed tomograms. Left carotid angiograms revealed the middle meningeal arteriovenous fistula at the left middle fossa, which showed an characteristic drainages, i.e. mainly draining to the pterygoid venous plexus and the superior sagittal sinus, partially to the cavernous sinus. She was admitted to our ward and was treated only conservatively. Thirty-five days after head injury, her complaints improved remarkably and left carotid angiograms, performed on the next day, disclosed complete disappearance of the previous fistula, and suggested the point of fistula clearly. Documenting the computed tomogram and the angiograms of our case, possible mechanism of fistula formation and its spontaneous cure was discussed. The middle meningeal arteriovenous fistula was formed by the interaction between the direct or indirect influence of head injury and anatomical, histological and pathological factors of meningeal vessels themselves. Spontaneous cure of the fistula resulted from thrombosis at the point of fistula. In our case, irregularity of the wall of anterior middle meningeal artery on the repeated angiograms supported this view.

Middle meningeal artery trauma

We present the case of a patient who had the symptoms of a subarachnoid hemorrhage but was subsequently found to have an unusual combination of a separate traumatic pseudoaneurysm and a traumatic arteriovenous fistula of the middle meningeal artery. A review of the literature revealed a difference in the clinical course of patients with traumatic pseudoaneurysms compared to that of patients with arteriovenous fistulas. Patients who were found to have traumatic pseudoaneurysms of the middle meningeal artery frequently manifested signs of delayed hemorrhage. This mechanism may account for the prolonged lucid intervals exhibited in some patients subsequently found to have epidural hematomas.

Traumatic middle meningeal arteriovenous fistula and primitive trigeminal artery

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Emergency occlusive techniques

Emergency occlusive therapy may be indicated in the management of acute arterial injury or expanding arteriovenous fistula. Intra-arterial occlusion may be performed at the time of diagnostic angiography. Selective placement of catheters permits percise diagnosis and management. We wish to report eight cases to demonstrate the efficacy of different occlusive agents. No adverse reactions were noted in this series of patients. We feel that emergency occlusive therapy is rapid and safe. It may facilitate and occasionally obviate surgical management.

Traumatic middle meningeal arteriovenous fistula. Report of 3 cases and analysis of 32 cases

Three cases of traumatic middle meningeal arteriovenous fistula are reported and 32 cases, including ours, reported in the literature are analyzed. In these 32 cases, the appearance of the arteriovenous fistula at angiography exhibited one of three different configurations: type 1, the middle meningeal vein shows a railway configuration; type 2, the middle meningeal vein shows a rod configuration; type 3, extravasation of contrast material and/or pseudoaneurysm are concomitant. In correlating the angiographic type and clinical course, the following tendencies were observed: the clinical course was good in type 1, fair in type 2 and poor in type 3, respectively.

[Carotid-cavernous fistulas by tearing or rupture of the meningo-hypophysial trunk or of one of its branches. Anatomo-radiologic study of 4 cases. Pathogenic hypotheses]

Thr authors report observations relative to four cases of traumatic carotid-cavernous fistulas for which angiographic pictures were similar. Autopsy examination permitted in two cases to establish that the tentorial branch of the meningo-hypophyseal trunk was involved in the genesis of both fistulas. One case was from a rupture, the other from tearing of that branch. Further examination of these two cases showed an absence of sphenoid bone fracture which suggested that any arterial perforation or shearing process could be excluded. Thus the pathogenic hypothesis of PARKINSON is further sustained. The authors suggest that the observed arterial lesions may be due to tensions occuring at the proximal part of branches of the meningo-hypophyseal trunk. Such tensions may be carried out through tractions on the posterior meningeal walls of the cavernous sinus when trauma occur on the posterior temporal area and the petrous bone. Such traction forces were shown to be real in one case where a fracture of the dorsum sellae and a bilateral caroti-cavernous fistula were caused by a bilateral temporo-petrous trauma.

Traumatic fistula between a lacerated middle meningeal artery and a diploic vein; case report

A traumatic fistula occurring between a lacerated middle meningeal artery and a diploic vein was treated conservatively, and was no longer demonstrable at follow-up examination about 1 1/2 years after the injury.

[Bilateral traumatic paralysis of the abducent nerves]

Two cases of bilateral traumatic abducens palsy are reported. The onset of the ocular symptomatology, several hours after the head injury, suggests a possible involvement of the branches of the meningeal dorsal artery supplying the extradural trait of the 6th cranial nerve.

Traumatic pseudoaneurysm and arteriovenous fistula involving the middle meningeal artery

Two cases of traumatic pseudoaneurysm and arteriovenous fistula involving the middle meningeal artery are reported with a review of the world literature on these specific entities. The two conditions appear to evolve through similar mechanisms and may lead to a confusing clinical picture. High quality angiography is important in making an early diagnosis, prior to performing a definitive surgical procedure.

Extravasation of angiographic contrast material from a torn middle meningeal artery into the diploi. Case report

✓ Extravasation of contrast material during angiography in a head-injured patient was shown at operation to have occurred because of a fistula between a lacerated meningeal artery and the diploic spaces within the skull. Usually such extravasation is regarded as diagnostic evidence of an epidural or subdural hematoma, as had been suggested erroneously by the angiogram in this case.