Traumatic middle meningeal artery pseudoaneurysm and subsequent fistula formation with the cavernous sinus: case report

Traumatic middle meningeal arteriovenous fistulas (MMAVFs): an exploratory systematic review

This study aims to systematically review case reports and case series in order to compare the postoperative course of conservative, endovascular and surgical treatments for traumatic dural arteriovenous fistulas predominantly supplied by the middle meningeal artery (MMAVFs), which usually occur following head trauma or iatrogenic causes. We conducted a comprehensive search of PubMed, Embase, Scopus, Web of Science, and Google Scholar until June 23rd, 2024. Three cohorts were defined based on the treatment modality employed. The primary outcomes were the rates of overall obliteration and postoperative complications, with all-cause mortlality considered as secondary outcome. A total of 61 studies encompassing 78 pooled MMAVFs were included in the qualitative analysis. The predominant demographic consisted of males (53.9%) with a median age of 50.5 (IQR: 33.5-67.5) years. The main etiologies for fistula formation were head trauma (75.6%), cranial neurosurgical procedures (11.5%) and endovascular embolization (8.97%). Venous drainage patterns were categorized as follows based on anatomical confluence: Class I (16.7%), II (14.1%), III (12.8%), IV (14.1%), V (7.7%), and VI (3.9%). Regarding treatment efficacy, the overall obliteration rate was 89.74%, achieved through endovascular (95.83%), surgical (64.29%) or conservative (93.75%) approaches. In terms of safety, the overall postoperative complication rate was 6.49% with an all-cause mortality rate of 8.97%, predominantly observed in the surgical group (35.71%). Our systematic review highlights the challenging management of traumatic MMAVFs, frequently associated with head injuries. Endovascular therapy has emerged as the predominant treatment modality, demonstrating markedly higher rates of fistula obliteration, reduced all-cause mortality, and fewer postoperative complications.

Endovascular treatment of traumatic anterior communicating artery-cavernous sinus fistula

Traumatic anterior communicating artery (AcomA)-cavernous sinus (CS) fistula is rare. Flow diverter (FD) deployment associated with coiling may be an alternative but has never been reported. We reported such a case. A 61-year-old man who was involved in a traffic accident presented with progressive exophthalmos for 2 weeks. Digital subtraction angiography showed a fistula between the AcomA and CS. First, the fistula was coiled. Then, the FD was deployed to cover the rupture point of the AcomA. The fistula was obliterated. Postoperatively, the patient recovered well, and his eye symptoms disappeared. Follow-up angiography showed no recurrence of the fistula. Therefore, for traumatic AcomA-CS fistula, FD deployment associated with coiling may be a feasible alternative.

Post-traumatic Middle Meningeal Artery Pseudoaneurysm Treated With Endovascular Coil Embolization

Pseudoaneurysms of the middle meningeal artery are rare events following head trauma. Given the potential for significant morbidity and mortality associated with pseudoaneurysm rupture, it is recommended that they be treated early. Endovascular embolization is a viable alternative to open surgical intervention. Here, we describe a case of an incidentally found middle meningeal artery pseudoaneurysm in a patient with a carotid-cavernous fistula after head injury. The pseudoaneurysm was treated with endovascular coil embolization.

The Middle Meningeal Artery: Branches, Dangerous Anastomoses, and Implications in Neurosurgery and Neuroendovascular Surgery

The middle meningeal artery (MMA) has always been the workhorse corridor for devascularization of dural-based intracranial lesions and, more recently, has been established as a target for the endovascular management of chronic subdural hematomas. The MMA anatomy is complex and deceitful, and its territory of irrigation (including cranial nerves) is poorly understood. Furthermore, MMA variations and anastomoses are more frequent than expected, which may predispose to procedure-related morbidity. A literature search was conducted in electronic databases per PRISMA guidelines for studies describing normal and abnormal MMA anatomy including variations in MMA origin and dangerous anastomoses. Our institutional case series of greater than 100 MMA embolizations for management of chronic subdural hematomas were reviewed for abnormal MMA anatomy, and clinically relevant case examples are presented. In this article, we provide a comprehensive review of the MMA to provide a better understanding and appreciation of this artery, including pearls and pitfalls, that we hope will aid the neurosurgeon and neurointerventionalist in safely tackling these lesions.

Delayed Spontaneous Resolution of a Traumatic Middle Meningeal Artery Pseudoaneurysm

Patient: Male, 42-year-old

Final Diagnosis: Middle meningeal artery pseudoaneurysm

Symptoms: Migraine

Medication:—

Clinical Procedure: —

Specialty: Radiology

Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review

PURPOSE OF REVIEW

The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers.

RECENT FINDINGS

To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.

Spontaneous Thrombosis of a Middle Meningeal Arteriovenous Fistula With Subsequent Pseudoaneurysm Formation: Case Report and Review of Literature

BACKGROUND AND IMPORTANCE

Middle meningeal artery (MMA) pseudoaneurysms and middle meningeal arteriovenous fistulas (MMAVFs) are rarely reported after head injury. We report an unusual case of delayed MMA pseudoaneurysm formation after spontaneous thrombosis of an MMAVF, and review existing literature on MMAVF treatment and results.

CLINICAL PRESENTATION

A 59-yr-old male presented with a 5-d history of worsening left-sided headaches, followed by nausea, lethargy, and difficulty with speech. Non-contrast computed tomography demonstrated a left temporal intraparenchymal hemorrhage (IPH) and an acute left-sided subdural hematoma (SDH). Cerebral angiography found abnormal shunting between the right MMA and the right sphenoparietal sinus, consistent with an MMAVF. During the course of admission, the patient's neurological condition deteriorated requiring craniotomy for evacuation of SDH and IPH. Given the presumed incidental nature of the contralateral MMAVF, conservative management was recommended. Follow-up imaging 2 mo after surgery revealed spontaneous thrombosis of the right MMAV. Repeat imaging 5 mo later revealed an MMA pseudoaneurysm at the prior fistulous site, which was subsequently embolized with Onyx, occluding the pseudoaneurysm and the MMA both proximal and distal to the pseudoaneurysm.

CONCLUSION

Spontaneous thrombosis of an MMAVF is rare and only seen in 13.1% of cases. However, subsequent delayed formation of an MMA pseudoaneurysm has not been described. Our case therefore demonstrates that MMAVF thrombosis may not indicate complete healing of the underlying injury to the MMA, and suggests the need for continued follow-up of such lesions despite initial apparent resolution.

Traumatic Middle Meningeal Arteriovenous Fistula of Non-fractured Site Detected by Four-dimensional Computed Tomography Angiography: A Case Report

Middle meningeal arteriovenous fistula (MMAVF) of a non-fractured site is extremely rare, and the clinical characteristics are still unclear. We report a case of delayed onset of venous infarction due to an MMAVF following a fall accident. A 69-year-old man sustained multiple trauma due to a fall accident. Head computed tomography (CT) showed traumatic subarachnoid hemorrhage, a left subdural hematoma, and skull fracture in his right temporal bone, all of which were managed conservatively. Five days after his admission, he suddenly exhibited total aphasia and right hemiparesis. Emergent CT revealed sporadic low-density areas in his left cerebral hemisphere, and four-dimensional CT angiography (4D-CTA) showed dilatation of the left middle meningeal artery and early venous drainage in the cavernous sinus and anterior temporal diploic vein (ATDV). A series of hemodynamics of 4D-CTA revealed early venous filling of ATDV interrelated with retrograde upward flow to high convexity in the venous phase. The MMAVF was successfully obliterated by transarterial coil embolization. We herein describe this case of MMAVF in which 4D-CTA was useful for the diagnosis.

N-butyl cyanoacrylate embolization of a traumatic pseudoaneurysm and arteriovenous fistula of the middle meningeal artery

We report a case of combined traumatic pseudoaneurysm and arteriovenous fistula of the middle meningeal artery, which presented clinically 1 year after initial head trauma. A 39-year-old male presented with seizure activity after a closed head injury from a fall. He was hospitalized for multiple intraparenchymal hemorrhages and ultimately discharged 2 weeks later without neurologic deficits. One year later, he presented with a new right anterior temporal intraparenchymal hemorrhage after a syncopal event. Selective angiography of the right external carotid artery demonstrated a chronic appearing traumatic laceration of the proximal middle meningeal artery with a 6 × 10 mm pseudoaneurysm and a single fistula with venous varix draining into the lateral pterygoid veins. The pseudoaneurysm and arteriovenous fistula were successfully embolized with n-butyl cyanoacrylate.

Chronic Epidural Hematoma Caused by Traumatic Intracranial Pseudoaneurysm of the Middle Meningeal Artery: Review of the Literature with a Focus on this Unique Entity

BACKGROUND

Pseudoaneurysms of the middle meningeal artery represent fewer than 1% of all intracranial aneurysms; it can be associated with different patterns of intracranial hemorrhages. A chronic epidural hematoma (CEDH) caused by post-traumatic pseudoaneurysm of the middle meningeal artery (MMA) has not yet been reported.

CASE DESCRIPTION

A 17-year-old male patient was referred to our unit after a car accident, with head trauma and presented motor and language deficits. After a brain computed tomography scan that revealed a left temporal epidural hematoma, the patient underwent surgery with complete hematoma drainage and recovery. After 5 months, he developed a chronic epidural hematoma secondary to a pseudoaneurysm of the MMA, as shown by cerebral angiography. We also reviewed the literature to evaluate the state of the art concerning the diagnosis and management of patients affected by CEDH.

CONCLUSIONS

Pseudoaneurysms are considered unstable because of the poor support of the aneurysmal wall. They tend to progressively increase in size and ultimately rupture, leading to delayed intracranial bleeding. A univocal definition of the interval of time between the acute head trauma and the diagnosis to classify the CEDH is still debated. To our knowledge, this is the first case described of a CEDH secondary to a pseudoaneurysm of the MMA. In our study we suggest defining CEDHs as extradural hematomas diagnosed and/or treated 21 days or more after a head injury.

Intracranial Hemorrhage Secondary to a Delayed Cerebral Pseudoaneurysm Rupture 18 Years after Cranial Trauma

We report the case of a 38-year-old male with a previous history of severe cranial trauma and subsequent large subdural and subarachnoid hemorrhage on whom an emergent hematoma evacuation was performed with a good outcome and follow-up. Despite a good clinical evolution, the patient experienced a further intracranial hematoma 18 years after the trauma, with severe aphasia and mild right hemiparesis. After complete etiological study, two cranial pseudoaneurysms were observed in the cerebral angiography. Endovascular treatment was successfully completed, achieving full embolization without complications. No rebleeding was detected during follow-up. The patient had a good clinical outcome at 3 months and achieved complete recovery. Cranial pseudoaneurysm rupture is a rare cause of intracerebral hemorrhage, especially if the trauma occurs years before the bleeding.

Posttraumatic Middle Meningeal Artery Pseudoaneurysm: Case Report and Review of the Literature

BACKGROUND

Intracranial pseudoaneurysm is a rare entity, with few cases described in the literature, and is mostly associated with a history of traumatic brain injury. Traumatic aneurysms comprise <1% of all intracranial aneurysms. In particular, middle meningeal artery (MMA) aneurysms are uncommon and usually caused by a skull fracture in the temporal region. About 40 traumatic MMA aneurysms are reported in the literature, and only 28 nontraumatic aneurysms are reported, usually related to high-flow conditions. The behavior of these aneurysms is largely unknown: both spontaneous resolution and aneurysm growth, leading to subsequent rupture, have been reported. Surgical and endovascular management are feasible for MMA aneurysms; however, the criterion standard treatment is not defined.

CASE DESCRIPTION

We report the case of a traumatic pseudoaneurysm of the right MMA treated with an endovascular approach and provide a review of the literature.

CONCLUSIONS

Aneurysms of the MMA are a rare entity that must be taken into account in the setting of a traumatic brain injury or predisposing factors. The diagnosis and aggressive treatment are mandatory, preventing the devastating consequences of their rupture. Endovascular and surgical techniques are well defined and available, even though there is not a demonstrated superiority in any of them.

Onyx™ embolization for an angiographically progressive traumatic pseudoaneurysm of the middle meningeal artery: A case report and literature review

Traumatic pseudoaneurysm of the middle meningeal artery (MMA) is a rare entity that is typically associated with a high risk of rupture and mortality. Only few such cases of pseudoaneurysms have been reported in the medical literature and therefore, the optimal management of this condition remains undetermined. The present study reported on a female patient (age, 20 years) with angiographically progressive pseudoaneurysm of the MMA after head injury. The pseudoaneurysm was successfully embolized with the liquid, non-adhesive embolic agent Onyx™. The mechanism of formation of traumatic pseudoaneurysms, their imaging characteristics and the optimal treatment plan were discussed.

Contrecoup Injury-Induced Middle Meningeal Arteriovenous Fistula Detected by Time-of-Flight Magnetic Resonance Angiography and Magnetic Resonance Arterial Spin Labeling: Case Report and Review of the Literature

BACKGROUND

Middle meningeal arteriovenous fistula (MM-AVF) is rare; however, it will sometimes be followed by intracranial hemorrhage or progressive symptoms caused by abnormal shunt flow. Radiological examination and endovascular treatment of this condition have recently advanced; thus, we have described the pathogenesis, clinical features, and appropriate diagnostic and therapeutic management of MM-AVF. We also reviewed the reported data of the past 35 years, including 30 cases of MM-AVF.

CASE DESCRIPTION

We report the case of 24-year-old man who had presented with right tinnitus who had experienced previous head trauma on the opposite side to the tinnitus ear. Time-of-flight magnetic resonance angiography and magnetic resonance arterial spin labeling findings were suggestive of MM-AVF, and catheter angiography confirmed MM-AVF with shunt flow draining into the cavernous sinus. Endovascular transarterial embolization was performed, and the MM-AVF was embolized successfully using detachable coils and n-butyl-2-cyanoacrylate. The tinnitus disappeared completely immediately after the treatment.

CONCLUSIONS

MM-AVF is caused, not only by coup injury, but also by contrecoup injury. Time-of-flight magnetic resonance angiography and magnetic resonance arterial spin labeling are useful for detecting MM-AVF. Endovascular transarterial embolization is an effective and safe treatment.

Delayed Intracerebral Hemorrhage After Pseudoaneurysm of Middle Meningeal Artery Rupture: Case Report, Literature Review, and Forensic Issues

BACKGROUND

Traumatic pseudoaneurysm of the middle meningeal artery (PMMA) is rare. Its rupture is associated with high mortality, so an early diagnosis is recommended for this risky condition. In the absence of a specific guideline, computed tomography (CT), digital subtraction angiography, and CT angiography (CTA) are proposed for its diagnosis. CTA is the technique of choice even if it is almost never performed, especially in mild head injury. We report a rare case of a delayed rupture of PMMA, analyzed from a forensic point of view.

METHODS

Fifteen days after mild blunt head trauma, characterized by temporal fracture and a small hemorrhage near the rim, a wide intraparenchymal hemorrhage (IPH) occurred. The onset of IPH was marked by neurologic deterioration and arm paralysis. Immediate head CT showed IPH, and CTA showed PMMA. Prompt surgery could not help patient survival. The goal of autopsy was to formulate the cause of death and to individuate potential medical negligence.

RESULTS

In the literature, 16 cases of 54 are related to PMMA (26%) and are associated with IPH. IPH can be acute or delayed. Eight cases of acute IPH and 8 cases of delayed IPH (including our case), both coexisting with PMMA, are described. The literature review showed that the association of temporal rim fracture and a small hemorrhage nearby is highly predictive of PMMA formation.

CONCLUSIONS

Therefore, in the presence of these 2 risk factors after heat trauma, CTA is strongly suggested.

Endovascular management of acute epidural hematomas: clinical experience with 80 cases

OBJECTIVE

Small acute epidural hematomas (EDHs) treated conservatively carry a nonmeasurable risk of late enlargement due to middle meningeal artery (MMA) lesions. Patients with EDHs need to stay hospitalized for several days, with neurological supervision and repeated CT scans. In this study, the authors analyzed the safety and efficacy of the embolization of the involved MMA and associated lesions.

METHODS

The study group consisted of 80 consecutive patients harboring small- to medium-sized EDHs treated by MMA embolization between January 2010 and December 2014. A literature review cohort was used as a control group.

RESULTS

The causes of head injury were falls, traffic-related accidents (including car, motorcycle, and pedestrian vs vehicle accidents), and assaults. The EDH topography was mainly temporal (lateral or pole). Active contrast leaking from the MMA was seen in 57.5%; arteriovenous fistulas between the MMA and diploic veins were seen in 10%; and MMA pseudoaneurysms were found in 13.6% of the cases. Embolizations were performed under local anesthesia in 80% of the cases, with N-butyl-2-cyanoacrylate, polyvinyl alcohol particles, or gelatin sponge (or a combination of these), obtaining MMA occlusion and complete resolution of the vascular lesions. All patients underwent follow-up CT scans between 1 and 7 days after the embolization. In the 80 cases in this series, no increase in size of the EDH was observed and the clinical evolution was uneventful, without Glasgow Coma Scale score modification after embolization and with no need for surgical evacuation. In contrast, the control cohort from the literature consisted of 471 patients, 82 (17.4%) of whom shifted from conservative treatment to surgical evacuation.

CONCLUSIONS

This study suggests that MMA embolization is a highly effective and safe method to achieve size stabilization in nonsurgically treated acute EDHs.

Management of Unruptured Traumatic Middle Meningeal Artery Pseudoaneurysms through Onyx Embolization

Traumatic pseudoaneurysms of the middle meningeal artery (MMA) represent less than 1% of all intracranial aneurysms, and occur mostly in association with temporal bone fractures following head trauma. Given the unknown natural history, it is unclear whether they should be treated. We present two cases of MMA pseudoaneurysms discovered during trauma workups. The first patient is a 44-year-old male with severe traumatic brain injury (TBI) following a motor vehicle accident. The patient was found to have two right-sided middle meningeal artery pseudoaneurysms that were treated successfully with Onyx® (Medtronic, Minneapolis, MN) embolization. The second patient is a 56-year-old male that sustained a severe TBI and skull fracture following a motorcycle collision. Angiography demonstrated an unruptured right MMA aneurysm, which was also treated successfully with Onyx embolization. MMA pseudoaneurysms occur rarely in the setting of severe traumatic injuries. In select patients, treatment by an experienced neuro-interventionalist can prevent highly morbid future intracranial hemorrhages with minimal risk of complications.

Middle meningeal artery aneurysm: Case report

Background:

Aneurysms of meningeal middle artery (MMA) are extremely rare. These aneurysms are of two types: true aneurysm and pseudoaneurysm. The true type is usually seen with pathologic conditions. Pseudoaneurysms, on the other hand, are associated with a skull fracture. Epilepsy caused by MMA aneurysm has never been described to our knowledge. We report a case of true aneurysm isolated from MMA revealed by epilepsy.

Case Description:

A 57-year-old patient with a history of high blood pressure developed epilepsy which was treated by valproic acid. Initial scalp electroencephalography (EEG) showed seizure activity arising from the right temporal area. Epilepsy had become drug-resistant. Cerebral angiography revealed an aneurysm of the right middle meningeal artery without any other intraparenchymal anomaly. The interrogation did not reveal any history of family aneurysm. The patient underwent surgery with coagulation of the aneurysm and the MMA. The aneurysm was intradural in contact with the temporal cortex, and the surrounding brain tissues were preserved. The operative follow-up was favorable with amelioration of convulsions with a single antiepileptic. We planned to stop antiepileptic treatment according to electroencephalograms.

Conclusions:

Aneurysms of the MMA are rare. Their mode of revelation by seizures is unusual. The factors of rupture are not known. When isolated, their physiopathology is identical to that of the aneurysms of the Willis polygon. Their management uses the same techniques as for other cerebral aneurysms.

Middle meningeal arteriovenous fistulas: A rare and potentially high-risk dural arteriovenous fistula

Background:

Middle meningeal arteriovenous fistulas (MMAVFs) are rare lesions with a poorly established natural history. We report our experience with patients with MMAVFs who presented with intracranial hemorrhage.

Methods:

We reviewed our prospectively maintained endovascular database for patients with MMAVFs, who were treated by embolization during a 15-year period. Hospital and outpatient medical records and imaging studies were reviewed.

Results:

Nine patients with MMAVFs, who presented with intracranial hemorrhage, underwent embolization (mean age 60.3 years, range 21–76; four male and five female). Four patients presented after trauma and five after spontaneous hemorrhage. All nine patients were angiographically cured after embolization of the fistula with liquid embolic agents (n = 8) or coils (n = 1). There were no procedure-related complications.

Conclusion:

MMAVFs represent a rarely reported class of vascular lesions. They are typically associated with trauma, but also develop spontaneously, and may be associated with intracranial hemorrhage, which warrants classification of these lesions as high risk. Endovascular treatment is safe and effective and should be considered for these patients, particularly for those who have lesions with intracranial venous drainage.

Traumatic pseudoaneurysm of the middle meningeal artery with an arteriovenous fistula on a non-fractured site

We describe a rare case of a combined traumatic pseudoaneurysm and arteriovenous fistula (AVF) of the middle meningeal artery (MMA) on a non-fractured site. A 24-year-old man was admitted to our hospital with head trauma. He underwent a craniotomy and removal of an epidural hematoma on the right side. Twenty-five days later, he complained of pulsatile tinnitus on the left non-fractured side. Angiography revealed a markedly dilated proximal MMA with flow shunting to the pterygoid plexus. We performed proximal occlusion on the proximal MMA for the traumatic pseudoaneurysm and the AVF of the MMA using coils. Although immediate angiography showed retrograde contrast filling from the collateral vessels into the distal part of the pseudoaneurysm, follow-up angiography revealed that the lesion had successfully disappeared.

Acute formation of a pseudoaneurysm adjacent to a previously clipped anterior communicating artery aneurysm

Background:

Cerebral pseudoaneurysms, especially of the anterior communicating artery (ACoA), are rare.

Case Description:

Herein, the authors report a 66-year-old patient who underwent successful clip ligation of a small ruptured ACoA aneurysm. Eighteen days after surgery, he suffered from another episode of subarachnoid hemorrhage due to the rupture of a newly formed pseudoaneurysm adjacent to the previously clipped aneurysm. This pseudoaneurysm was treated through clip ligation as well.

Conclusion:

A pseudoaneurysm may rarely form adjacent to a previously clipped cerebral aneurysm and should be included in the differential diagnosis of recurrent subarachnoid hemorrhage. Potential mechanisms of formation and management strategies for this challenging problem will be discussed.

Traumatic pseudoaneurysm of the middle meningeal artery causing an intracerebral hemorrhage

Traumatic aneurysms comprise less than 1% of all intracranial aneurysms. Most of these aneurysms are actually false aneurysms, or pseudoaneurysms, which are caused by the rupture of entire vessel wall layers, with the wall of the aneurysm being formed by the surrounding cerebral structures. Traumatic pseudoaneurysms of the middle meningeal artery are also rare. Only four cases have been reported in the literature with intracerebral hematoma. In this paper, the authors report a case of a patient with a ruptured traumatic pseudoaneurysm of the MMA who presented with an intracerebral hematoma in the left temporal region immediately after trauma; the patient underwent endovascular treatment.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus

PURPOSE

Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

METHODS

A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus.

RESULTS

The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms.

CONCLUSION

A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Traumatic middle meningeal artery and fistula formation with the cavernous sinus: case report

BACKGROUND

In this study, we present a young patient with traumatic middle meningeal fistula treated with detachable balloon through the middle meningeal artery.

CASE DESCRIPTION

The case of a 22-year-old man with exophthalmos due to an arteriovenous fistula between the middle meningeal artery and the cavernous sinus at the base of the middle cranial fossa is reported. Complete embolization was performed with a detachable balloon and resulted in complete relief of the symptoms.

CONCLUSION

The middle meningeal fistula can be caused by head trauma; selective external carotid angiogram is necessary for correct diagnosis, and endovascular embolization is an effective way.

Traumatic extracranial pseudoaneurysm on the peripheral ophthalmic artery presenting as delayed intraparenchymal hematoma: case report

BACKGROUND

Extracranial pseudoaneurysm is barely noticed after head injury, and therefore, recognizing such sequels is amenable when there is severe initial injury, unexplained intracranial bleeding, or neurologic sequelae. We report such an unexpected case of intraorbital pseudoaneurysm presenting as delayed intraparenchymal hemorrhage.

CASE DESCRIPTION

A 71-year-old man with traumatic brain injury sustained delayed intraparenchymal hemorrhage after unremarkable surgical evacuation. Suspicious intraorbital mass was shown adjacent to the fracture line of medial orbital wall. Catheter angiogram revealed peripheral, extracranial ophthalmic artery pseudoaneurysm, and endovascular occlusion was attempted. The patient made gradual recovery with radiographic evidence of disappeared pseudosac and resolved intracranial hematoma.

CONCLUSION

Traumatic aneurysm of peripheral ophthalmic artery should be strongly suspected when there is skull fracture at the orbital wall or persistent or delayed intraparenchymal hemorrhage despite proper surgical hematoma evacuation, and in such case, swift endovascular occlusion can be done safely.

Traumatic pseudoaneurysm of the middle meningeal artery: possible indicators for early diagnosis in the computed tomography era

OBJECTIVE AND IMPORTANCE

Traumatic pseudoaneurysms of the middle meningeal artery, which are associated with high mortality, are difficult to detect early by CT. We provide serial CT scans to show the steps of their formation and suggest characteristics that could be useful in the detection.

CLINICAL PRESENTATION

A 25-year-old man was initially in deep coma had an anisocoric pupil after a traffic accident. Brain CT showed basal skull fracture and traumatic subarachnoid hemorrhage with severe brain swelling. Emergent decompressive craniectomy was performed, and 2 days later, an EDH appeared at the left temporal fossa. Careful examination of the image revealed a hypodense nodule inside the acute hematoma. He underwent craniotomy to remove the hematoma. Serial CT of the residual hematoma showed the gradual development of an organized hematoma around the hypodense nodule. The nodule had low density, which was strongly enhanced on CT after injection of contrast medium. The nodule was highly suspected to be a vascular lesion. A middle meningeal artery pseudoaneurysm was discovered through a 3-dimensional computed tomographic angiography. He underwent another craniotomy to remove the pseudoaneurysm.

INTERVENTION

The diagnostic approach was CT, 3-dimensional CT, and craniotomies.

CONCLUSION

Four CT findings may be useful for early diagnosis: (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. Three-dimensional computed tomographic angiography is an effective and noninvasive tool to confirm this diagnosis.

Cavernous Sinus Dural Arteriovenous Fistula Associated With the Development of Sphenoidal Ridge Meningioma -Case Report-

A 76-year-old man presented with a cavernous sinus (CS) dural arteriovenous fistula (AVF) associated with the development of a meningioma without venous sinus occlusion. Initial digital subtraction angiography did not reveal the CS dural AVF, which appeared simultaneously with the enlargement of the meningioma and lead to right oculomotor nerve paresis. In this case, the development of meningioma possibly increased the vascular tumor bed and affected the venous hemodynamic return, thus leading to the dural AVF.