Letters to Editor
further invasive procedure, DSA. This patient teaches a lesion that infundibulae may even arise at unusual location and should be distinguished from aneurysms. Source image may be of great help to diagnosis.
Hao Chen, Ming‑Hua Li Institute of Diagnostic and Interventional Radiology, The Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai 200233, China E‑mail: [email protected]
References 1. 2.
3. 4. 5.
Ebina K, Ohkuma H, Iwabuchi T. An angiographic study of incidence and morphology of infundibular dilation of the posterior communicating artery. Neuroradiology 1986;28:23‑9. Sun ZK, Li YD, Li MH, Chen SW, Tan HQ. Detection of infundibula using three‑dimensional time‑of‑flight magnetic resonance angiography with volume rendering at 3.0 Tesla compared to digital subtraction angiography. J Clin Neurosci 2011;18:504‑8. Unruptured intracranial aneurysms – Risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med 1998;339:1725‑33. Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm and arteriovenous malformation: A meta‑analysis. Stroke 1999;30:317‑20. Heiserman JE, Dean BL, Hodak JA, Flom RA, Bird CR, Drayer BP, et al. Neurologic complications of cerebral angiography. AJNR Am J Neuroradiol 1994;15:1401‑7.
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 1a and b]. Surgical excision of the aneurysm and evacuation of acute subcutaneous hematoma was performed [Figure 2a and b]. Histological diagnosis was pseudoaneurysm [Figure 2c and d]. The post‑operative course was uneventful. Recently there has been reports of STA pseudoaneurysms
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125402
a
b
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
Received: 06‑11‑2013 Review completed: 08‑11‑2013 Accepted: 18‑12‑2013
Ruptured pseudoaneurysm of the superficial temporal artery after craniotomy
a
b
c
d
Sir, Pseudoaneurysm of the superficial temporal artery (STA) after craniotomy is extremely rare[1‑8] 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 698
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
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Letters to Editor
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.[1‑8] 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.[2‑4,7,8] 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
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
pseudoaneurysm rupture with massive hemorrhage from a sutured skin incision.
Masaru Honda, Takeo Anda, Tokuhiro Ishihara1 Department of Neurosurgery, Shunan Memorial Hospital, 1‑10‑1 Ikunoyaminami, Kudamatsu, Yamaguchi 744‑0033, 1 Department of Pathology, Tokuyama Medical Association Hospital, 6-28 Higashiyama, Shunan, Yamaguchi 745‑8510, Japan E‑mail: [email protected]
References 1.
2.
3.
4. 5. 6. 7. 8.
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. 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. 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. 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. 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. 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. 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. Wang X, Chen JX, You C. Iatrogenic false aneurysm caused by surgery of a traumatic intracranial false aneurysm. Neurol India 2011;59:753‑5. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125406
Received: 07‑11‑2013 Review completed: 20‑11‑2013 Accepted 21‑12‑2013
699
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
further invasive procedure, DSA. This patient teaches a lesion that infundibulae may even arise at unusual location and should be distinguished from aneurysms. Source image may be of great help to diagnosis.
Hao Chen, Ming‑Hua Li Institute of Diagnostic and Interventional Radiology, The Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai 200233, China E‑mail: [email protected]
References 1. 2.
3. 4. 5.
Ebina K, Ohkuma H, Iwabuchi T. An angiographic study of incidence and morphology of infundibular dilation of the posterior communicating artery. Neuroradiology 1986;28:23‑9. Sun ZK, Li YD, Li MH, Chen SW, Tan HQ. Detection of infundibula using three‑dimensional time‑of‑flight magnetic resonance angiography with volume rendering at 3.0 Tesla compared to digital subtraction angiography. J Clin Neurosci 2011;18:504‑8. Unruptured intracranial aneurysms – Risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med 1998;339:1725‑33. Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm and arteriovenous malformation: A meta‑analysis. Stroke 1999;30:317‑20. Heiserman JE, Dean BL, Hodak JA, Flom RA, Bird CR, Drayer BP, et al. Neurologic complications of cerebral angiography. AJNR Am J Neuroradiol 1994;15:1401‑7.
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 1a and b]. Surgical excision of the aneurysm and evacuation of acute subcutaneous hematoma was performed [Figure 2a and b]. Histological diagnosis was pseudoaneurysm [Figure 2c and d]. The post‑operative course was uneventful. Recently there has been reports of STA pseudoaneurysms
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125402
a
b
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
Received: 06‑11‑2013 Review completed: 08‑11‑2013 Accepted: 18‑12‑2013
Ruptured pseudoaneurysm of the superficial temporal artery after craniotomy
a
b
c
d
Sir, Pseudoaneurysm of the superficial temporal artery (STA) after craniotomy is extremely rare[1‑8] 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 698
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
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
Letters to Editor
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.[1‑8] 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.[2‑4,7,8] 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
Neurology India | Nov-Dec 2013 | Vol 61 | Issue 6
pseudoaneurysm rupture with massive hemorrhage from a sutured skin incision.
Masaru Honda, Takeo Anda, Tokuhiro Ishihara1 Department of Neurosurgery, Shunan Memorial Hospital, 1‑10‑1 Ikunoyaminami, Kudamatsu, Yamaguchi 744‑0033, 1 Department of Pathology, Tokuyama Medical Association Hospital, 6-28 Higashiyama, Shunan, Yamaguchi 745‑8510, Japan E‑mail: [email protected]
References 1.
2.
3.
4. 5. 6. 7. 8.
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. 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. 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. 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. 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. 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. 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. Wang X, Chen JX, You C. Iatrogenic false aneurysm caused by surgery of a traumatic intracranial false aneurysm. Neurol India 2011;59:753‑5. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.125406
Received: 07‑11‑2013 Review completed: 20‑11‑2013 Accepted 21‑12‑2013
699
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
