Surgical Neurolog

Aneurysm

Traumatic middle meningeal artery aneurysm causing intracerebral

hematoma: a case report and review of literature

Manmohan Singh, Mch4, Faiz Uddin Ahmad, MBBS, Ashok K. Mahapatra, MchDepartment of Neurosurgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India

Received 7 October 2005; accepted 10 November 2005

Abstract Background: Traumatic aneurysms of middle meningeal artery (MMA) are rare. Traumatic MMA

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doi:10.1016/j.surneu.2

Abbreviations: C

hematoma; MMA, m

STA, superficial temp

4 Corresponding

11 26588207.

E-mail address: m

aneurysms usually present with extradural hematomas, whereas intradural intraparenchymal

hematomas are exceedingly rare.

Case Discussion: We report a 30-year-old man who presented 1 year after head injury with

spontaneous right frontal intraparenchymal hematoma. Investigations revealed a MMA pseudoa-

neurysm, which was successfully treated surgically.

Conclusion: Traumatic MMA pseudoaneurysm producing intracerebral hematoma (ICH) is rare and

can be listed as a cause of spontaneous acute ICH.

D 2006 Elsevier Inc. All rights reserved.

Keywords: Head injury; Intracerebral hematoma; Middle meningeal artery; Posttraumatic; Pseudoaneurysm

1. Introduction

Traumatic aneurysms of MMA are rare, and they usually

present with extradural hemorrhage [2,3]. Such lesions

presenting with ICH are extremely rare. It is important to

diagnose and treat these aneurysms at the earliest to prevent

catastrophic events. Association of MMA traumatic aneur-

ysms with skull fractures has been well documented [5,7].

In patients in whom fracture line crosses the MMA,

possibility of false aneurysm should be kept in mind.

Patients with traumatic pseudoaneurysms are more likely to

have delayed bleeds, which accounts for typical prolonged

lucid interval. This may explain the delayed appearance of

intracranial hemorrhages on CT scans. To the best of the

authors’ knowledge, only 2 such cases, who presented with

ICH, have been described in English literature [1,7]. We

report a patient with traumatic pseudoaneurysm of MMA,

who presented with spontaneous frontal intraparenchymal

hematoma, 1 year after trauma.

nt matter D 2006 Elsevier Inc. All rights reserved.

005.11.029

T, computerized tomography; ICH, intracerebral

iddle meningeal artery; MR, magnetic resonance;

oral artery.

author. Tel.: +91 11 26588700x4914; fax: +91

anmohan1972@gmail.com (M. Singh).

2. Case report

A 30-year-old man was admitted in February 2004, after

a road traffic accident, with history of unconsciousness for

20 minutes. On admission, patient was conscious but

irritable. Plain CT scan of head showed bifrontal contusions

without significant mass effect (Fig. 1). He was managed

conservatively and discharged 1 week later. In January

2005, he was admitted with complaints of sudden onset of

severe headache and one episode of generalized seizure.

Computed tomography scan of the head revealed a

hematoma in the right frontal lobe (Fig. 2). Because there

was no history of trauma immediately preceding his

symptoms, an angiogram was done to ascertain the cause

of bleed. Angiogram revealed a pseudoaneurysm, arising

from MMA (Fig. 3). He was taken up for surgery, and right

frontal craniotomy was performed. There was no extradural

hematoma, and surface of the dura was apparently normal.

On dural opening, the brain cortex was stuck to the dura.

The dura was gently separated of the cortex. On the inner

surface of dura, there was an irregular-shaped aneurysm

arising from the MMA, penetrating the cortex of the frontal

lobe. The parent vessel along with the aneurysm was

coagulated. Frontal hematoma was evacuated. Patient made

a good postoperative recovery and was well after 8 months

of follow-up.

y 66 (2006) 321–323

Fig. 2. Noncontrast CT scan of head showing right frontal lobe hematoma

with mass effect.

M. Singh et al. / Surgical Neurology 66 (2006) 321–323322

3. Discussion

Traumatic aneurysms of the MMA, although rare in

occurrence, have been known as an etiology of acute

epidural hematoma of delayed onset [2,3]. Schulze [10]

reported the first case of traumatic MMA aneurysm in 1957.

Until 2002, Bruneau et al [1] had reviewed 40 cases of

traumatic MMA aneurysms reported in the world literature.

However, such aneurysms causing ICH are distinctly rare.

There are only 2 cases of ICHs caused by rupture of

traumatic MMA pseudoaneurysms reported in English

literature until now [1,7]. Bruneau et al [1] reported a

64-year-old woman who suffered a massive spontaneous

intracerebral frontotemporal hemorrhage with ventricular

spread, caused by a traumatic pseudoaneurysm of the

MMA. Despite surgical evacuation, the patient died after

24 hours. Rambaugh et al [7] reported a 63-year-old woman

who presented with right temporal hematoma, and angiog-

raphy revealed an MMA false aneurysm at the level of

sphenoid ridge. The patient made a good recovery after

surgical evacuation of the hematoma. Two cases of non-

traumatic MMA aneurysms causing ICH have also been

described in literature [9,11]. Ushikoshi et al [11] reported

a patient with ICH caused by a nontraumatic aneurysm

arising from MMA that provided collateral flow to poste-

rior cerebral artery territory, after the parent artery was

blocked by atherosclerotic disease. Sandin et al [9] reported

a 46-year-old man who developed a spontaneous tempor-

oparietal hematoma after rupture of such an aneurysm. In

the reported cases, the usual delay between trauma and

abrupt neurologic deterioration varies from 3 to 30 days [8].

However, present case is unique in this respect, presenting

1 year after trauma. This, we believe, is the longest reported

delay in presentation until now.

The natural history of these aneurysms is not completely

known, but they have been demonstrated to grow on repeat

angiograms [6]. It is thought that they develop after a small

Fig. 1. Noncontrast CT scan of head showing bifrontal contusions.

tear in the meningeal artery, which is sealed off by a clot,

recanalizing later and forms a false lumen. These pseudoa-

neurysms gradually enlarge and rupture anytime [1]. Hence,

this aneurysm must always be treated expeditely, especially

because the surgical management is technically easy.

Kinoshita et al [4] recommended that the cases of

epidural hematoma treated conservatively should be fol-

lowed up by MR imaging and MR angiography using the fat

suppression technique to rule out formation of pseudoa-

neurysms. The presence of traumatic pseudoaneurysm

should be considered in those patients who show delayed

and abrupt neurologic deterioration because of the ICH after

head injury. In these patients, angiography should also

include external carotid artery injections, including manual

compression and occlusion of STA to remove confusion

from overlapping of STA branches [8].

Fig. 3. Right external carotid artery injection shows MMA aneurysm

(black arrow).

M. Singh et al. / Surgical Neurology 66 (2006) 321–323 323

4. Conclusion

Rupture of MMA pseudoaneurysm should be kept in

mind in the differential diagnosis of patients presenting with

delayed onset of intracranial hematoma after trauma.

Carotid artery angiography with external carotid artery

injection should be performed to rule out pseudoaneurysm

of MMA. Such patients should be managed surgically at the

earliest to prevent rebleed.

References

[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.

[2] Garza-Mercado R, Rangel RA. Extradural hematoma associated with

traumatic middle meningeal artery pseudo aneurysm. Report of two

cases. Neurosurgery 1979;5:200 -3.

[3] Kimora T, Sako K, Satoh M, Nakai H, Yonemasu Y, Takeuchi E,

Ishikura H. Post-traumatic pseudoaneurysm of the middle meningeal

artery. A case report. No Shinkei Geka 1995;23:1021-5.

[4] Kinoshita Y, Yasukouchi H, Tsuru E, Okudera T, Yokota A. Delayed

epidural bleeding caused by traumatic pseudo-aneurysm of the middle

meningeal artery: case report. No Shinkei Geka 2004;32:1139-43.

[5] Kuhn RA, Kugler H. False aneurysms of middle meningeal artery.

J Neurosurg 1950;7:106-14.

[6] Meder JF, Gaston A, Merienne L, Godon-Hardy S, Fredy D.

Traumatic aneurysms of the internal and external carotid arteries.

One case and review of literature. J Neuroradiol 1992;19:248-55.

[7] Rambaugh CL, Bergeron T, Kurze T. Intracranial vascular damage

associated with skull fracture: radiological aspects. Radiology 1972;

104:81-7.

[8] Roski RA, Owen M, White RJ, Takaoka Y, Bellon EM. Middle

meningeal artery trauma. Surg Neurol 1982;17:200 -3.

[9] Sandin JA, Salamat SA, Baskaya M, Dempsey RJ. Intracerebral

hemorrhage caused by the rupture of a non-traumatic middle

meningeal artery aneurysm. J Neurosurg 1999;90:951 -4.

[10] Schulze A. Seltene verlaufsformen epiduraler hamatome. Zentralbl

Neurochir 1957;17:40 -7.

[11] Ushikoshi S, Houkin K, Itoh F, et al. Ruptured aneurysm of the middle

meningeal artery associated with occlusion of the posterior cerebral

artery. J Neurosurg 1996;84:269-71.

Commentary

It is nice to learn from this case that a traumatic aneurysm

of the middle meningeal artery can cause an intracerebral

hematoma 1 year later, without an extradural hematoma.

Gerard Debrun, MD

29360 Paris, France