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Table of Contents    
LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 6  |  Page : 921-922

Traumatic giant pseudoa-neurysm of the middle meningeal artery causing intracerebral hematoma


Department of Neurosurgery, Goa Medical College and Hospital, Bambolim, Goa, India

Date of Submission10-Jul-2011
Date of Decision31-Jul-2011
Date of Acceptance18-Aug-2011
Date of Web Publication2-Jan-2012

Correspondence Address:
R Jinendra Kumar
Department of Neurosurgery, Goa Medical College and Hospital, Bambolim, Goa
India
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DOI: 10.4103/0028-3886.91387

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How to cite this article:
Kumar R J, Sundaram PK, Gunjkar JD. Traumatic giant pseudoa-neurysm of the middle meningeal artery causing intracerebral hematoma. Neurol India 2011;59:921-2

How to cite this URL:
Kumar R J, Sundaram PK, Gunjkar JD. Traumatic giant pseudoa-neurysm of the middle meningeal artery causing intracerebral hematoma. Neurol India [serial online] 2011 [cited 2014 Jul 12];59:921-2. Available from: http://www.neurologyindia.com/text.asp?2011/59/6/921/91387


Sir,

A 53-year-old male sustained a fall under the influence of alcohol and 4 days later, in February 2011, was admitted to hospital as he was observed to be behaving abnormally from the time of the fall. On examination, the Glasgow coma scale (GCS) score was 12 (E 4 M 5 V 3 ), with no cranial nerve or motor deficits. Noncontrast computerized tomography (NCCT) of the head done at admission revealed a linear fracture in the greater wing of the right sphenoid, extending laterally from near the foramen ovale into the squamous temporal bone [Figure 1]; there was also a small adjacent extradural hematoma (EDH). A well-demarcated, isodense, rounded 2.5 × 2.2 × 3 cm lesion was seen arisingfrom the skull base and extending upwards into the right temporal lobe; this lesion was capped by an intracerebral hematoma. A left temporal hemorrhagic contusion was also noted [Figure 2]. Both hematoma and contusion were not of sufficiently significant size to warrant immediate surgical evacuation.
Figure 1: Bone window shows a linear fracture line running across the greater wing of sphenoid, close to the foramen ovale

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Figure 2: Plain CT on admission shows a large isodense, rounded lesion surrounded by acute hematoma; temporal contusion seen on the opposite side

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Suspecting a vascular origin for the lesion arising from the skull base, a cerebral CT-angiography was done 24 hours later, which showed intense homogenous enhancement of the skull base lesion seen earlier on NCCT scan [Figure 3] and [Figure 4]; the middle meningeal artery (MMA) was seen in close relation to the base of this lesion [Figure 5]. The suspected aneurysm had grown in size (it was now 3.6 × 3.1 × 3.9 cm), with an increase in mass effect [Figure 6]. A right temporal craniotomy was done. Brisk extradural bleeding was noted from the region of the skull base even as the bone flap was being removed. The MMA was cauterized and the foramen spinosum occluded with bone wax to stop the bleeding. A fracture line along the greater wing of sphenoid was noted, along with an overlying 1.5 × 1.5 cm dural tear through which the inferior part of the intracerebral hematoma was visualized. After formal dural opening, a cortical incision was made in the middle temporal gyrus to reach the temporal hematoma, which was then evacuated. No well-formed aneurysm wall was encountered at the time of surgery. The dural tear was repaired with a pericranial graft. After surgery, the patient made a steady recovery. His GCS score improved to 14 over the next few days and he was discharged.
Figure 3: Coronal reconstruction of the contrast image shows the MMA (black arrow) at the base of the pseudoaneurysm and an adjacent small EDH

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Figure 4: Plain CT performed 24 hours later reveals increase in size of the isodense rounded lesion

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Figure 5: CT angiography (done 24 hours after admission) shows intense contrast enhancement of the lesion; ipsilateral MCA is seen separate from the lesion

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Figure 6: Coronal reconstruction of the contrast image shows a giant pseudoaneurysm capped by an acute bleed

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An emergency plain CT scan done after head trauma may well reveal an intracranial bleed, but an associated pseudoaneurysm of MMA (PMMA) is usually not obvious because of its small size. [1],[2],[3],[4],[5] Wang et al. reported a patient who gradually developed an extradural giant PMMA over a period of 46 days and on the basis of their findings put forth four CT findings that may be useful for early diagnosis of such lesions; these are (1) basal skull fracture in the temporal region, (2) hypodense nodule within an acute hematoma, (3) hypodense nodule within an organized and encapsulated hematoma, and (4) strong and homogenous enhancement of the hypodense nodule within an organized and encapsulated hematoma. [6] Our patient had CT findings similar to those reported by Wang et al., [6] but differed from their description in that the bleed was intracerebral and the progression much more rapid (only 4 days).

Intracerebral hematoma secondary to a traumatic PMMA is very rare. There are only six case reports of traumatic PMMA presenting with intracerebral bleed in the English literature. [1],[2],[3],[4],[5],[7] In all of these patients, the clinical presentation was with an intracerebral bleed, and the pseudoaneurysm was only later detected by angiography. There has been no report of a giant pseudoaneurysm with an associated intracerebral bleed in literature. Our patient presented with an intracerebral hematoma secondary to a giant traumatic PMMA that could be clearly visualized as a well-demarcated rounded structure on the initial NCCT itself.

 
  References Top

1.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. 1
[PUBMED]  [FULLTEXT]  
2.Bozzetto-Ambrosi P, Andrade G, Azevido-Filho H. Traumatic pseudoaneurysm of the middle meningeal artery and cerebral intraparenchymal hematoma: Case report. Surg Neurol 2006;66 Suppl 3:S29-31.  Back to cited text no. 2
    
3.Lim DH, Kim TS, Joo SP, 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. 3
[PUBMED]  [FULLTEXT]  
4.Paiva WS, de Andrade AF, Amorim RL, Figuerido EG, Texeira MJ. Traumatic pseudoaneurysm of the middle meningeal artery causing an Intracerebral Hemorrhage: Case report. Case Rep Med 2010;219572:3.  Back to cited text no. 4
    
5.Singh M, Ahmad FU, Mahapatra AK. Traumatic middle meningeal artery aneurysm causing intracerebral hematoma: A case report and review of literature. Surg Neurol 2006;66:321-3.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Wang CH, Lee HC, Cho DY. Traumatic pseudoaneurysm of the middle meningeal artery: Possible indicators for early diagnosis in the computed tomography era. Surg Neurol 2007;68:676-82.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Rumbaugh CL, Bergeron T, Kurze T. Intracranial vascular damage associated with skull fracture: Radiological aspects. Radiology 1972;104:81-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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