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CASE REPORT
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1820-1823

Traumatic Pseudoaneurysm of Middle Meningeal Artery with Delayed Presentation as Intracerebral Hematoma: A Report with Review of Literature


1 Department of Neuroimaging, Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission24-Mar-2019
Date of Decision17-May-2019
Date of Acceptance13-May-2019
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Chandrajit Prasad
Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.333471

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 » Abstract 


Background: Post-traumatic pseudoaneurysm of the middle meningeal artery is a rare entity. We report an atypical case of a delayed presentation as parenchymal hemorrhage due to a ruptured middle meningeal artery pseudoaneurysm.
Case Description: A 22-year-old man with an alleged history of cranial trauma following a road traffic accident presented 10 days later with a new right temporal intraparenchymal hemorrhage. The CT revealed a differentially hypodense circumscribed structure in the anterior temporal location eccentrically in the hematoma. The cerebral angiogram depicted a pseudoaneurysm arising from the middle meningeal artery. The patient underwent craniotomy and excision of the aneurysm. On follow up, the patient was asymptomatic and had no focal neurological deficits.
Conclusion: Despite its rare occurrence, meningeal artery pseudoaneurysm should be considered as a possible etiology of a post-traumatic delayed presentation as an intracerebral hematoma. Prompt diagnosis and management are warranted in view of the mortality and morbidity.


Keywords: Angiography, delayed, intraparenchymal hematoma, middle meningeal artery, post-traumatic, pseudoaneurysm
Key Messages: Meningeal artery pseudoaneurysm should be considered as a possible etiology of a post-traumatic delayed presentation as an intracerebral hematoma. Prompt diagnosis and management are warranted in view of the mortality and morbidity.


How to cite this article:
Kulanthaivelu K, Siddiqui SM, Prasad C, Shashidhar A. Traumatic Pseudoaneurysm of Middle Meningeal Artery with Delayed Presentation as Intracerebral Hematoma: A Report with Review of Literature. Neurol India 2021;69:1820-3

How to cite this URL:
Kulanthaivelu K, Siddiqui SM, Prasad C, Shashidhar A. Traumatic Pseudoaneurysm of Middle Meningeal Artery with Delayed Presentation as Intracerebral Hematoma: A Report with Review of Literature. Neurol India [serial online] 2021 [cited 2022 Jan 26];69:1820-3. Available from: https://www.neurologyindia.com/text.asp?2021/69/6/1820/333471




Aneurysms of the middle meningeal arteries are an uncommon entity. The lesion may be a true aneurysm which is usually associated with hypertension or high flow states[1] or a pseudoaneurysm in the setting of trauma.[2] The most frequent manifestation of the traumatic pseudoaneurysms is an epidural hematoma which may have acute or delayed presentation. Sometimes, it manifests as subdural or subarachnoid hemorrhage.[3] Isolated intracerebral hematoma is a rare presentation and has hitherto been reported in only 10 cases.[4]

Here, we discuss a case of delayed intraparenchymal hemorrhage due to a rupture of a middle meningeal artery pseudoaneurysm.


 » Case Report Top


A 22-year-old man presented at our casualty following an alleged history of a road traffic accident with transient loss of consciousness and vague headache. CT at admission revealed [Figure 1] fracture of the right squamous temporal and the parietal bones with no obvious parenchymal change in the right temporal region. There were punctate hemorrhagic contusions of the left temporal and inferior frontal region suggestive of a contrecoup injury. The patient was medically managed and discharged the next day.
Figure 1: CT done at admission reveals (a) No significant parenchymal changes in the right temporal region (b) Punctate haemorrhagic contusions of the left temporal and inferior frontal region suggestive of a contrecoup injury (c) Fracture of the squamous temporal and the parietal bones

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10 days later, the patient presented again with increasing headache and altered sensorium. On admission, the patient was conscious but agitated. The Glasgow Coma Scale score was 15/15. On examination, both pupils were regular and reactive to light.

Contrast Enhanced CT [Figure 2] performed showed an interval appearance of an acute right temporal hematoma with a differentially hypodense circumscribed structure at the periphery of the hematoma. Intense artery-iso-dense enhancement of the structure raised the suspicion of a pseudoaneurysm.
Figure 2: CT repeated at 8 days (a) post-injury reveals right temporal acute haemorrhage with a differential hypodense circumscribed structure at the periphery of the hematoma (b) Intense artery iso-dense enhancement of the structure raising the suspicion of pseudoaneurysm

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Diagnostic cerebral angiogram of the right external carotid artery [Figure 3] with selective injection of the internal maxillary artery [Figure 4] was performed the same day, and demonstrated a pseudoaneurysm in relation to the bifurcation of the right middle meningeal artery (MMA) that was directed medially. Remarkable stasis of contrast in the pseudoaneurysm and the proximal vessel was observed alongside.
Figure 3: Digital subtraction angiography – (a) Lateral projection of the right External Carotid Artery injection reveals the pseudoaneurysm in relation to the bifurcation of the right MMA, (b) Frontal projection reveals the neck of the aneurysm in relation to the bifurcation of the MMA and directed medially. Of note is the stasis of contrast in the aneurysm and the proximal vessel

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Figure 4: (a) Lateral and b) frontal projection of the internal maxillary injection further delineates the relations of the aneurysm with MMA bifurcation. The stasis of contrast from the prior injection appearing as a ghost in the subtracted images is remarkable

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The patient underwent emergency right frontotemporal craniotomy with evacuation of the temporal hematoma. The middle meningeal artery pseudoaneurysm was identified in relation to the inner surface of the dura. The vessel was ligated proximal and distal to the pseudoaneurysm and the affected segment of vessel along with pseudoaneurysm was excised. Histopathological examination revealed wall of aneurysmal sac with hematoma.

The in-hospital course was uneventful, and the patient was discharged. At three months follow up, he had no interval complaints or focal neurological deficits. CT at follow up [Figure 5] was suggestive of gliosis in the right temporal lobe with no abnormal enhancement or new parenchymal change.
Figure 5: Contrast-enhanced CT at three months follow up reveals gliosis in the temporal pole on the right, no enhancing structure, and no new parenchymal changes

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 » Discussion Top


Traumatic pseudoaneurysms of the middle meningeal artery are a rare entity. Hitherto, approximately 50 cases have been reported since the first description of the lesion, which dates to 1957. True aneurysms demonstrate histological architectural similarity to congenital aneurysms of cerebral vasculature and arise in the setting of the systemic disease like Paget's, uncontrolled hypertension, high flow dural arteriovenous fistulae, meningioma with hypervascularity, skull cavernous hemangioma, Moya-Moya phenomenon, occlusion of arteries in the pial vasculature. The common denominator of these conditions is relatively high flow with hemodynamic wall stress.

Approximately 70-90% of post-traumatic pseudoaneurysms of MMA have an associated temporoparietal bony fracture along the course of the vessel as a putative cause. No fracture is evident in remaining cases, where traction on the vessel wall is the probable cause.

Pseudoaneurysm etiopathogenesis in trauma of the middle meningeal artery involves fractured bony rim induced injury of the adventitia and intimomedia followed by formation of a contained intramural hematoma which undergoes fibrous re-organization. Clot destabilization by the hemodynamic stress of the arterial flow renders the lesion progressively rupture-prone.[5] It is possible that the delayed clinical manifestations follow this timeline that leads to the delayed rupture of the pseudoaneurysm.[6] The time interval between trauma and pseudoaneurysmal rupture ranges between 1-30 days.[4] However, the rupture in most of these scenarios occurs in the extra-axial compartment. Hitherto, the most common descriptions of pseudoaneurysms with parenchymal hematoma have been in the acute setting.[3] Possibly the arterial mural injury was large, and the contained clot was rapidly walled-off presenting as a pseudoaneurysm immediately. The patient under discussion is remarkable for the delayed presentation as an intra-axial hematoma.

The natural history of MMA pseudoaneurysms is not well known. Spontaneous regression, although infrequent, has been described.[7] Relentless increase in the size of the lesion is the common course with these lesions. Unruptured pseudoaneurysms of the middle meningeal artery have been reported earlier in at least four accounts.

The angiographic characteristics of MMA pseudoaneurysms have been elucidated earlier,[8] in terms of the eccentric location, longer distance from a bifurcation point, absence of a discrete neck, and irregularity of the luminal outline. The hold-up of contrast, the abnormality in the pre and the post aneurysmal segments of the vessel and contrast persistence in the late phase of the injection are noteworthy characteristics. Although usually small with sizes less than 5 mm, the dimensions may occasionally exceed 3 cm.

Prognosis of MMA pseudoaneurysms is not generally favorable,[4] with mortality in up to 20% of cases. A possible confound in this scenario is the co-existence of the severity of the initial traumatic brain injury. On the contrary, the true aneurysms which stem from an altogether different etiology, have a less frequent presentation as intracerebral hematoma and generally portend a better outcome.[9]

This condition warrants prompt treatment. Surgical excision of pseudoaneurysm and management of the mass effect, has been the most frequent adopted treatment. The cure may alternatively be achieved through endovascular means by parent vessel occlusion with cyanoacrylate glue provided mass effect is not prohibitive.

To conclude, post-traumatic pseudoaneurysm of the middle meningeal artery ought to be considered as a possible etiology for a delayed parenchymal hemorrhage. Given its poor prognosis, prompt investigation with CT angiography and digital subtraction angiography should be considered for a patient with craniocerebral trauma with delayed presentation of deteriorating neurological status and hematoma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Berk ME. Aneurysm of the middle meningeal artery. Br J Radiol 1961;34:667-8.  Back to cited text no. 1
    
2.
Holland HW, Thomson JL. Aneurysm of the middle meningeal artery. Clin Radiol 1965;16:334-8.  Back to cited text no. 2
    
3.
Albert FK, Oldenkott P, Sigmund E. Subarachnoid hemorrhage and intracerebral hematoma in injury of the middle meningeal artery (aneurysma spurium). Zentralbl Neurochir 1989;50:153-6.  Back to cited text no. 3
    
4.
Bruneau M, Gustin T, Zekhnini K, Gilliard C. Traumatic false aneurysm of the middle meningeal artery causing an intracerebral hemorrhage: Case report and literature review. Surg Neurol 2002;57:174-8.  Back to cited text no. 4
    
5.
Lim D-H, Kim T-S, Joo S-P, Kim SH. Intracerebral hematoma caused by ruptured traumatic pseudoaneurysm of the middle meningeal artery: A case report. J Korean Neurosurg Soc 2007;42:416-8.  Back to cited text no. 5
    
6.
Aoki N, Sakai T, Kaneko M. Traumatic aneurysm of the middle meningeal artery presenting as delayed onset of acute subdural hematoma. Surg Neurol 1992;37:59-62.  Back to cited text no. 6
    
7.
Liliequist B. Roentgenologic appearances of traumatic lesions of middle meningeal artery: Report of two cases. Acta Radiol Diagn (Stockh) 1967;6:513-8.  Back to cited text no. 7
    
8.
Higazi I, El-Banhawy A, El-Nady F. Importance of angiography in identifying false aneurysm of the middle meningeal artery as a cause of extradural hematoma: Case report. J Neurosurg 1969;30:172-6.  Back to cited text no. 8
    
9.
Kähärä VJ. Middle meningeal artery aneurysm. Case illustration. J Neurosurg 1999;91:518.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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