Korean J Neurotrauma.  2017 Oct;13(2):162-166. 10.13004/kjnt.2017.13.2.162.

Traumatic Intracerebral and Subarachnoid Hemorrhage Due to a Ruptured Pseudoaneurysm of Middle Meningeal Artery Accompanied by a Medial Sphenoid Wing Dural Arteriovenous Fistula

• Park JW
• Lee JY

• KMID: 2394554
• DOI: http://doi.org/10.13004/kjnt.2017.13.2.162

Abstract

Traumatic pseudoaneurysms of middle meningeal artery (MMA) and medial sphenoid wing dural arteriovenous fistula (dAVF) are rare. These lesions usually result from traumatic brain injury, and associated with skull fracture. In this paper, the authors report a case of a patient with a ruptured traumatic pseudoaneurysm of MMA and medial sphenoid wing dAVF presented with an intracerebral hemorrhage in the left temporal region and subarachnoid hemorrhage. These lesions were completely obliterated by endovascular treatment, and the patient was recovered without any neurologic deficit. However, 18-day after the procedure, delayed neurologic deficits were developed due to cerebral vasospasm.

Keyword

Aneurysm, false; Arteriovenous fistula; Subarachnoid hemorrhage, traumatic

MeSH Terms

Aneurysm, False*
Arteriovenous Fistula
Brain Injuries
Central Nervous System Vascular Malformations*
Cerebral Hemorrhage
Humans
Meningeal Arteries*
Neurologic Manifestations
Skull Fractures
Subarachnoid Hemorrhage*
Subarachnoid Hemorrhage, Traumatic
Temporal Lobe
Vasospasm, Intracranial

Figure

• 

  FIGURE 1 Initial radiological images after trauma. (A, B) Brain computed tomography (CT) showed intracerebral hemorrhage in the left temporal lobe with diffuse and large amount of subarachnoid hemorrhage and subdural hemorrhage at the left hemisphere. (C) Brain CT angiography revealed that abnormal vascular structure, considered as pseudoaneurysms, at the distal segment of the left lesser sphenoid ridge (arrow).

• 

  FIGURE 2 Left external carotid angiogram. (A) anteroposterior view, (B) lateral view showed a multilobulated pseudoaneurysm at the distal segment of the lesser sphenoid ridge (large arrow). Retrograde contrast filling through the left superior ophthalmic vein (double arrow) and middle meningeal artery-middle meningeal vein fistula (double arrow head) was also shown. (C) Cone-beam computed tomography image showed a multilobulated pseudoaneurysm at the distal segment of the lesser sphenoid ridge (large arrow) and the left superior ophthalmic vein (double arrow). Between these, complex vascular connections at the lesser sphenoid ridge resulting in medial sphenoid ridge dural arteriovenous fistula was shown.

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  FIGURE 3 Superselective angiogram of the left middle meningeal artery (MMA). (A) anteroposterior view, (B) lateral view revealed an appropriate position of distal microcatheter tip (large arrow) showing a pseudoaneurysm (arrow head) and retrograde contrast filling through the left superior ophthalmic vein (double arrow). (C, D) N-butyl cyanoacrylate cast after embolization (large arrow). (E, F) Post-embolization external carotid angiogram showed complete occlusion of pseudoaneurysm, medial sphenoid ridge dural arteriovenous fistula and MMA-middle meningeal vein fistula.

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  FIGURE 4 (A) Post-embolization computed tomography showed n-butyl cyanoacrylate cast at the dural vascular channel (arrow), (B) psneudoaneurysm (arrow), (C) proximal and distal segment of the left middle meningeal artery according to a pseudoaneurysm (arrow and arrow head, respectively).

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  FIGURE 5 Radiologic images 15 days after endovascular embolization with motor weakness and dysarthria. (A, B) Brain computed tomography (CT) showed multifocal low density lesions at the left middle cerebral artery (MCA) territory. (C) CT angiography revealed sparse vasculature of distal segment of the left MCA preserving M1 patency (large arrows). (D) Left internal carotid angiogram showed multiple luminal irregularities and narrowing at the distal segment of MCA (small arrows).

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