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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 6  |  Page : 698--699

Ruptured pseudoaneurysm of the superficial temporal artery after craniotomy

Masaru Honda1, Takeo Anda1, Tokuhiro Ishihara2,  
1 Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu, Yamaguchi 744-0033, Japan
2 Department of Pathology, Tokuyama Medical Association Hospital, 6-28 Higashiyama, Shunan, Yamaguchi 745-8510, Japan

Correspondence Address:
Masaru Honda
Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu, Yamaguchi 744-0033
Japan




How to cite this article:
Honda M, Anda T, Ishihara T. Ruptured pseudoaneurysm of the superficial temporal artery after craniotomy.Neurol India 2013;61:698-699


How to cite this URL:
Honda M, Anda T, Ishihara T. Ruptured pseudoaneurysm of the superficial temporal artery after craniotomy. Neurol India [serial online] 2013 [cited 2020 Apr 2 ];61:698-699
Available from: http://www.neurologyindia.com/text.asp?2013/61/6/698/125406


Full Text

Sir,

Pseudoaneurysm of the superficial temporal artery (STA) after craniotomy is extremely rare [1],[2],[3],[4],[5],[6],[7],[8] and they seldom rupture. [2]

A 57-year-old man was brought with sudden onset loss of consciousness. Computed tomography (CT) revealed subarachnoid hemorrhage and CT-angiography confirmed distal anterior cerebral artery aneurysm at the right A2-A3 junction. Emergency clipping was successfully performed. Patient was given prophylactic triple-H therapy to prevent vasospasm. CT done on the following day revealed a right temporal subcutaneous mass (3 cm diameter 0 at the inferior end of skin incision. The lesion was non-pulsatile with no bruits or thrills and was managed conservatively. On postoperative day-10 there was sudden profuse hemorrhage (1800 ml, estimated) through the sutured skin incision and the patient went into hemorrhagic shock. Three-dimensional CT-angiography confirmed the subcutaneous mass as a partially thrombosed giant aneurysm at the frontal branch of the right STA [Figure 1]a and b. Surgical excision of the aneurysm and evacuation of acute subcutaneous hematoma was performed [Figure 2]a and b. Histological diagnosis was pseudoaneurysm [Figure 2]c and d. The post-operative course was uneventful.{Figure 1}{Figure 2}

Recently there has been reports of STA pseudoaneurysms and literature. [3],[6] in most reported cases the lesions were pulsatile and expanding and non-presented with bleeding [1],[2] and in none the bleeding was life-threatening disrupting an already sutured skin incision. The most plausible cause for formation of pseudoaneurysm is trauma to the STA by skin incision, a pin head-holder, thread removal and subcutaneous drains. [1],[2],[3],[4],[5],[6],[7],[8] In the present case, we believe a needle injury to the frontal branch during subcutaneous closure resulting in slow bleeding and and pseudoaneurysm formation. Terterov and colleagues have suggested that triple-H therapy might accelerate the formation of pseudoaneurysm. [6] Our patient was also given triple-H therapy. A pre-existing arterial wall abnormality might be another contributing factor. [3],[5],[6] Differential diagnoses for STA pseudoaneurysm include vascular tumor, arteriovenous fistula, meningeal artery aneurysm with bony erosion, subcutaneous lipoma, abscess and localized hematoma. [4],[5] In this case, partial thrombosis might be responsible for absence of pulsations or bruit and also headache. [8] Only one patient with bleeding from an STA pseudoaneurysm has been reported, occurring after craniotomy. [2] In that patient, the aneurysm was at the outside of a skin flap, thus preventing subcutaneous hemorrhage. The reported interval between craniotomy and aneurysm formation varied between 4 days and 3 months. [3],[6] Post-operative acute subcutaneous hematoma formation may indicate pseudoaneurysm formation as in this patient. [2] Surgical excision is the most optimal treatment. [2],[3],[4],[7],[8] During hematoma evacuation, we paid close attention to preventing anesthesia-induced hypotension and hence that there is no risk of worsening of symptomatic vasospasm. In addition to surgical excision, catheter embolization has been successfully performed. [5],[6] Percutaneous thrombin injection has also been performed with caution, but remains controversial. [1] In this patient, our decision to manage the swelling conservatively might not have been the correct decision. An aggressive approach would have prevented the life-threatening hemorrhage. We caution the surgeons dealing with this rare entity should anticipate such a complication. To the best of our knowledge, this case is probably the first report of pseudoaneurysm rupture with massive hemorrhage from a sutured skin incision.

References

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