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| LETTER TO EDITOR |
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| 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
| Date of Submission | 07-Nov-2013 |
| Date of Decision | 20-Nov-2013 |
| Date of Acceptance | 21-Dec-2013 |
| Date of Web Publication | 20-Jan-2014 |
Correspondence Address:
Masaru Honda
Department of Neurosurgery, Shunan Memorial Hospital, 1-10-1 Ikunoyaminami, Kudamatsu, Yamaguchi 744-0033
Japan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.125406
How to cite this article:
Honda M, Anda T, Ishihara T. Ruptured pseudoaneurysm of the superficial temporal artery after craniotomy. Neurol India 2013;61:698-9 |
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: (a) Source image of 3-dimensional computed tomography (CT) showing a partially thrombosed aneurysm.(b) Three-dimensional CT angiography revealing a giant aneurysm originating from the frontal branch of the superficial temporal artery
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 | Figure 2: (a) Disrupted sutured-skin incision in the center of the photo as a crevasse. An aneurysm is located under the discolored skin to the right of this crevasse (arrow). (b and c) Intraoperative photograph showing giant pseudoaneurysm at the anterior branch of the superficial temporal artery (captured by two silk strings). (d) Histologically, the pseudoaneurysm wall consisted of fibroblasts and connective tissue without elastic or smooth muscle tissues (H and E, ×40). Bar indicates 10 μm
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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 | |  |
| 1. | Bobinski L, Boström S, Hillman J, Theodorsson A. Postoperative pseudoaneurysm of the superficial temporal artery (S.T.A.) treated with Thrombostat (thrombin glue) injection. Acta Neurochir (Wien) 2004;146:1039-41. 
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| 2. | Fernández-Portales I, Cabezudo JM, Lorenzana L, Gómez L, Porras L, Rodríguez JA. Traumatic aneurysm of the superficial temporal artery as a complication of pin-type head-holder device. Case report. Surg Neurol 1999;52:400-3.
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| 3. | Hakan T, Ersahin M, Somay H, Aker F. Pseudoaneurysm of the superficial temporal artery following revision of a middle cerebral artery aneurysm clipping: Case report and review of the literature. Turk Neurosurg 2011;21:430-4.
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| 4. | Manzon S, Nguyen T, Philbert R. Bilateral pseudoaneurysms of the superficial temporal artery following reconstruction of the frontal sinus: A case report. J Oral Maxillofac Surg 2007;65:1375-7.
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| 5. | Shimoda M, Ikeda A, Sato O, Watabe T. A case of multiple superficial temporal artery pseudoaneurysms following craniotomy. No Shinkei Geka 1988;16:797-800.
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| 6. | Terterov S, McLaughlin N, Martin NA. Postcraniotomy superficial temporal artery pseudoaneurysm in the setting of triple H therapy: A case report and literature review. Surg Neurol Int 2012;3:139.
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| 7. | Tsutsumi M, Kawano T, Kawaguchi T, Kaneko Y, Ooigawa H. Pseudoaneurysm of the superficial temporal artery following craniotomy-Case report. Neurol Med Chir (Tokyo) 2000;40:261-3.
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| 8. | Wang X, Chen JX, You C. Iatrogenic false aneurysm caused by surgery of a traumatic intracranial false aneurysm. Neurol India 2011;59:753-5.
[PUBMED] |
[Figure 1], [Figure 2]
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