Korean J Neurotrauma.  2015 Oct;11(2):167-169. 10.13004/kjnt.2015.11.2.167.

Intraoperative Endovascular Embolization of Middle Meningeal Artery and a Pseudoaneurysm by Using N-Butyl 2-Cyanoacrylate for Hemostasis during Operation of Acute Epidural Hemorrhage

• Kim DH
• Lee JY
• Jeon HJ
• Cho BM
• Park SH
• Oh SM

• KMID: 2378280
• DOI: http://doi.org/10.13004/kjnt.2015.11.2.167

Abstract

A 21-year-old female presented with acute epidural hemorrhage (EDH) on the left temporal region associated with skull fracture after traffic accident. She was neurologically deteriorated at four-hour after an admission, and follow-up computed tomography revealed increased amount of EDH. Under the general anesthesia, emergency craniotomy was performed. During the surgery, massive bleeding from the base of middle cranial fossa was observed. However, we could not identify an origin of bleeding and foramen spinosum due to brain swelling and obscured surgical field. Consequently, her systolic blood pressure was dropped to 60 mm Hg with >110 beat/min of heart rate. Therefore, we decided to perform an intraoperative angiography after gauze packing into the middle cranial fossa. Intraoperative angiography showed a large pseudoaneurysm with massive contrast leakage of the middle meningeal artery (MMA). Intraoperative endovascular embolization of the pseudoaneurysm and MMA by using n-butyl-2-cyanoacrylate was done. After that, her vital sign became stable, and we could complete the operation after the achievement of adequate hemostasis. Intraoperative angiography and endovascular embolization of MMA was effective in achieving adequate hemostasis in case with brisk bleeding from the middle cranial fossa could not be controlled in an open surgical field.

Keyword

Hematoma, epidural, cranial; Embolization, herapeutic; Hemostasis

MeSH Terms

Accidents, Traffic
Anesthesia, General
Aneurysm, False*
Angiography
Blood Pressure
Brain Edema
Cranial Fossa, Middle
Craniotomy
Emergencies
Enbucrilate
Female
Follow-Up Studies
Heart Rate
Hematoma, Epidural, Cranial
Hemorrhage*
Hemostasis*
Humans
Meningeal Arteries*
Skull Fractures
Vital Signs
Young Adult
Enbucrilate

Figure

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  FIGURE 1 Initial brain computed tomography reveals acute epidural hemorrhage (EDH) on the temporal region (A) and follow-up brain CT obtained 4 hours after admission shows increased amount of EDH (B).

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  FIGURE 2 Intraoperative angiography of the left external carotid artery (A) depicts a large pseudoaneurysm (white arrow in A) and contrast leakage (white arrowheads in A) from the middle meningeal artery (MMA) which appeared torn and irregular. Native image (B) demonstrates glue case in a pseudoaneurysm, MMA and extravasation into the epidural space. Completion control angiography (C) shows complete occlusion of a pseudoaneurysm and MMA without extravasation.

• 

  FIGURE 3 Postoperative computed tomography (CT) (A) shows no residual epidural hemorrhage with hyperdense materials in middle cranial fossa made by n-butyl-2-cyanoacrylate. CT 4 months after the operation (B) revealed decreased amount of hyperdense materials in middle cranial fossa and no residual hematoma.

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