Surgical Neurology 66 (2006) S3:29 – S3:32 www.surgicalneurology-online.com
Traumatic pseudoaneurysm of the middle meningeal artery and cerebral intraparenchymal hematoma: case report Patricia Bozzetto-Ambrosi, MD4, Gustavo Andrade, MD, Hildo Azevedo-Filho, DM, FRCS (ED)1 Hospital da Restaurac¸a˜o, University of Pernambuco, Recife 52071-000, Brazil Received 29 June 2006; accepted 24 August 2006
Background: Pseudoaneuryms of the MMA are rare lesions, accounting for less than 1% of all intracranial aneurysms. Case Description: We report a case of a spontaneous intracerebral hematoma that DSA revealed as ispilateral traumatic PMMA. The lesion was managed through an endovascular approach, and definitive embolization of pseudoaneurysm and parent vessel with histoacryl injection was carried out. Recovery and follow-up were uneventful. We discuss the management of those lesions, emphasizing the current neuroendovascular tools and techniques. Conclusion: Pseudoaneurysm of the MMA is uncommon but has a potential aggressive natural history. As it can occur with different patterns of intracranial hemorrhage, the external carotid arteries have to be included in hemorrhagic investigational DSA. Once diagnosed, it must be treated. The minimally invasive endovascular approach and definitive embolization of pseudoaneurysm and parent vessel with histoacryl injection are safe and effective. D 2006 Published by Elsevier Inc.
Intraparenchymal hematoma; Middle meningeal artery aneurysm; Pseudoaneurysm; Endovascular therapy; Ebolization
1. Introduction Pseudoaneurysms of the MMA are rare lesions and a known cause of intracranial hemorrhage after head injury. They can be associated with skull fractures and several different bleeding patterns. Because of their potential morbidity and mortality, once diagnosed, they must be treated as an emergency.
down he probably hit his head on the floor. On admission, he presented with impairment of consciousness, had a GCS score of 12, was dysarthric, and had a left hemiparesis. The physical examination revealed a healthy-looking man in no distress, afebrile, with 140/110 mm Hg blood pressure level, and 68 beats per minute heart rate. He had superficial
2. Case report A 39-year-old man was admitted to our emergency department after an episode of dizziness at home followed by loss of consciousness. He was standing, and when he fell Abbreviations: AVM, arteriovenous malformation; CT, computed tomography; DSA, digital subtraction angiography; GCS, Glasgow Coma Scale; MMA, middle meningeal artery; PMMA, pseudoaneurysm of the middle meningeal artery. 4 Corresponding author. E-mail address: [email protected]
(P. Bozzetto-Ambrosi). 1 Address reprint requests to: Prof Hildo Azevedo-Filho, Apipucos, Recife 52071-000, Brazil. Tel.: +55 81 32221354; fax: +55 81 32212899. 0090-3019/$ – see front matter D 2006 Published by Elsevier Inc. doi:10.1016/j.surneu.2006.08.048
Fig. 1. Axial CT images showing an intraparenchymal hematoma that extends to the cortical surface.
P. Bozzetto-Ambrosi et al. / Surgical Neurology 66 (2006) S3:29–S3:32
Fig. 2. Right external carotid angiograms (lateral and anteroposterior projections) demonstrating a PMMA arising from the posterior branch.
abrasion in the left temporal region and no signs of skull base fracture. Cardiovascular, pulmonary, and abdominal examination findings were normal. The cranial nerves were normal. His personal and medical history was otherwise unremarkable, but he has been a social drinker with controlled hypertension and under antihypertensive medication. Axial CT images showed a large subcortical hematoma that measured 6 7 5 cm (estimated volume of 55 cm3) without extension into the ventricular system. There was some surrounding edema and mass effect upon the ipsilateral ventricle and midline shift (Fig. 1). As the hematoma was large and near the surface of the brain and shift of structures were great, an emergency craniotomy was performed with evacuation of the hematoma. The surgery was performed on an emergency basis, and the staff necessary to operate the DSA equipment very rarely can be mobilized during night shifts. The hematoma’s cavity and contents were thoroughly inspected in searching for possible vascular anomalies, but no particular abnormal tissue was identified. The consciousness improved immediately after the surgery. A cerebral DSA was performed the following day wherein the vertebral, internal carotid, and external carotid arteries were examined routinely. It revealed a pseudoaneurysm in the posterior branch of the MMA (Fig. 2). An endovascular approach was performed, under local anesthesia and conscientious sedation.
Through the right common femoral artery, a 6F guiding catheter (Envoy 6F, Cordis, Miami, FL, USA) was positioned in the ispilateral external carotid artery. Using a coaxial technique, we carefully navigated a microcatheter (Excelsior 1018, Boston Scientific, Redmond, WA, USA) and a 0.014-in microguidewire (Transcend, Boston Scientific) to reach the immediate proximal arterial segment. Before any injection, a 20% glue concentration was prepared, using 0.5 mL of histoacryl (Histoacryl; B Braun Melsungen, Germany) and 2.0 mL of Lipiodol (Guerbet, Paris, France). A contrast injection was done, confirming the adequate position of the microcatheter’s tip, adjacent to the pseudoaneurysm. The glue was injected, filling in the pseudoaneurysm lumen, the proximal, and distal arterial segments (Fig. 3). The recovery was uneventful, as he was discharged after 5 days. He continues to be followed clinically, without further scheduled DSA. 3. Discussion Traumatic aneurysms result from a direct injury to the arterial wall or from acceleration-induced shear. Cervical, cerebral, or meningeal artery can be affected, and it develops within hours after trauma, the majority being false aneurysms . Pseudoaneurysm of the MMA accounts for 27% of all intracranial traumatic aneurysms and for less than 1% of all intracranial aneurysms . True saccular aneurysms of the MMA are also extremely rare and are associated with pathologic conditions such as Paget’s disease, dural AVMs, meningiomas, moyamoya disease, occlusion of a cerebral artery or abnormal site of origin of a meningeal artery that chronically increases blood flow, and hemodynamic stress on the wall [9,11,14]. The presentation of PMMA depends on the injury of the MMA. Damage to the MMA with cranial fractures may cause epidural hematomas, traumatic aneurysms, and arteriovenous fistulae [2,4,5,8,11-13]. A fracture line is found in 92% of these cases, and usually the fractures cross the groove of the MMA [2,4,6,8]. The intracranial part of the MMA has thinned areas and medial layer defects, where a tear may be followed by hematoma formation confined
Fig. 3. Microcatheterization with the tip adjacent to the PMMA. Glue was injected under real-time digital subtraction fluoroscopy control (roadmapping), filling the pseudoaneurysm, the proximal, and distal vessel segments. A final DSA control, lateral view, shows the total occlusion of the posterior branch (MMA) without retrograde filling of the lesion.
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within the dural layers, thus limiting the bleeding. As the hematoma resolves and the wall fibroses, a small pseudoaneurysmal sac may develop, with subsequent rupture risk. The aneurysm may be located in the weakest part of the arterial wall but not necessarily adjacent to or beneath the fracture line . Association with subarachnoid intraparenchymatous or with mixed types of hemorrhage has been described, but is less common [2,4,8,11]. The most frequent presentation of a traumatic pseudoaneurysm, occurring in 70% of cases, is with an acute or delayed epidural hematoma [4,8]. The routine use of high-resolution DSA for examining the vertebral, internal carotid, and external carotid arteries is recommended to identify the etiology of hemorrhage and the characteristics of the underlying vascular lesions, leading to a better decision by the neurosurgical team. If available in the operating room, an intraoperative DSA should be obtained immediately after emergent decompression of an acute intracerebral hemorrhage. Traumatic pseudoaneurysms are typically demonstrated by irregular wall, absence of a true neck, and a peripheral location . Angiographically occult vascular malformations, which are frequently the cause of lobar hemorrhage, were excluded in the present case. Dural vascular lesions can cause intracranial hemorrhage. Rupture of arterialized leptomeningeal veins results in intracranial hemorrhages in cases of dural AVMs. Ruptured meningeal artery aneurysms should be considered as a possible hemorrhagic origin. Freckmann et al  reported a systematic review of cerebral angiograms in 446 (892 MMAs) head trauma patients, revealing the presence of angiographically demonstrable injuries of the MMA in 18 patients (4%) and an arteriovenous fistula of the MMA in 8 cases (1.8%). It is vital to emphasize the importance of external carotid artery documentation in the standard 4-vessel DSA [7,10,14]. Traumatic PMMA may regress, thrombose, enlarge, or rupture. Late, often severe bleeding may occur in up to 60% with an associated mortality of 50% . The interval between trauma and secondary pseudoaneurysm rupture ranges from 1 to 30 days [2,4,12]. Bruneau et al  reported a case of intracerebral frontotemporal hemorrhage caused by rupture of a PMMA with fatal evolution 1 day after surgery, illustrating the potential morbidity and mortality of these lesions . Nowadays, neurointerventional therapy is widely used as the first approach for some traumatic neurovascular lesions, being minimally invasive, feasible, and effective . Sparing the related artery is possible when there is a favorable neck and the aneurysm is not fusiform , which is very unusual with regard to pseudoaneurysms. In our case, the surgical treatment would consist in parent artery occlusion, which can also be done safely by endovascular route. A definitive treatment can be obtained with occlusion of the proximal parent vessel segment, the pseudoaneurysm lumen, and the distal segment, avoiding the risk of distal retrograde filling. Definitive embolic agents are obviously preferable, with glue and coils being the most used. With
coils, it is necessary to cross the pseudoaneurysm, reach the distal parent vessel segment, occlude it, and then, pull back the catheter and occlude proximally. The advantage is the absolutely precise deployment of detachable coils, but crossing a pseudoaneurysm with a microcatheter and guidewire is dangerous and rupture may occur. With the glue, it is necessary to reach only the proximal segment, avoiding the pseudowall, and then the progression of embolic agent can occur into blood flow by injection pressure. Once the proximal segment, the pseudoaneurysm lumen, and the distal segment are occluded with histoacryl, there is no risk of recanalization . 4. Conclusion Pseudoaneurysm of the MMA is uncommon but has a potential aggressive natural history. As it can occur with different patterns of intracranial hemorrhage, the external carotid arteries have to be included in hemorrhagic investigational DSA. Once diagnosed, it must be treated. The minimally invasive endovascular approach and definitive embolization of pseudoaneurysm and parent vessel with histoacryl injection have shown to be very safe and effective. References  Andrade G, Abath C, Marques R, Brito N. Endovascular treatment of cervical and facial vascular traumatic lesions. Int Neuroradiol 2003;9(2):144 - 5.  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 2000;57:174 - 8.  Cognard C, Weil A, Tovi M, Castaings L, Rey A, Moret J. Treatment of distal aneurysms of the cerebellar arteries by intraaneurysmal injection of glue. AJNR Am J Neuroradiol 1999;20:780 - 4.  Flores JS, Vaquero J, Garcia Sola R, Rossi E, Martinez R, Martinez P, Santos H, Bravo G. Traumatic false aneurysms of the middle meningeal artery. Neurosurgery 1986;18:200 - 3.  Freckmann N, Sartorand H, Herrmann D. Traumatic arteriovenous fistulae of the middle meningeal artery and neighboring veins or dural sinuses. Acta Neurochir 1981;55(3-4):273 - 81.  Holland HW, Thomson JL. Aneurysm of the middle meningeal artery. Clin Radiol 1965;16:334 - 8.  Holmes B, Harbaugh RE. Traumatic intracranial aneurysms: a contemporary review. J Trauma 1993;35:855 - 60.  Ishii R, Ueki K, Ito J. Traumatic fistula between a lacerated middle meningeal artery and a diploic vein: case report. J Neurosurg 1976;44:241 - 4.  Kahara VJ. Middle meningeal artery aneurysm: case illustration. J Neurosurg 1999;91:518.  Kobata H, Tanaka H, Tada Y, Nishirara K, Fujiwara A, Kuroiwa T. Intracerebral hematoma due to ruptured nontraumatic middle meningeal artery aneurysm: case report. Neurol Med Chir 2001;41:611 - 4.  Koebbe CJ, Horowitz MB. A rare case of a ruptured middle meningeal aneurysm causing intracerebral hematoma in a patient with Moyamoya disease. AJNR Am J Neuroradiol 2004;25:574 - 6.  Roski R, Owen M, White RJ, Takaoka Y, Bellon EM. Middle meningeal artery trauma. Surg Neurol 1982;17:200 - 3.  Suzuki S, Endo M. Efficacy of endovascular surgery for the treatment of acute epidural hematomas. AJNR Am J Neuroradiol 2004;25:1177 - 80.  Zubkov YN, Matsko DE, Pak VA. Saccular aneurysms of meningeal artery: case report. Neurosurgery 1998;42:664 - 6.