Vol. 117 No. 2 February 2014
Traumatic pseudoaneurysm of the superficial temporal artery: case report and review of the literature Josep Rubio-Palau, MD, DDS,a Ada Ferrer-Fuertes, MD,a Eloy García-Díez, MD,b Jordi Garcia-Linares, MD, DDS, PhD,c Carles Martí-Pagès, MD, PhD,a and Ramón Sieira-Gil, MDa Hospital Clínic de Barcelona and Hospital Sant Joan de Déu, Barcelona, and Hospital Germans Trias i Pujol, Badalona, Spain
Pseudoaneurysm of the superficial temporal artery is an uncommon complication of a blunt trauma. It usually presents as a pulsating mass in the frontotemporal area a few weeks after the injury. Doppler ultrasonography, angiography, or computed tomographic angiography can aid or confirm the diagnosis. The treatment of choice is the surgical resection of the pseudoaneurysm and ligation of the vessels. We report a case of a pseudoaneurysm of the frontal branch of the superficial temporal artery and review the literature. (Oral Surg Oral Med Oral Pathol Oral Radiol 2014;117:e112-e114)
Pseudoaneurysm is the result of total or partial rupture of the arterial wall, usually after a blunt trauma, with the formation of a hematoma and organization. Its occurrence in the superficial temporal artery is a rare cause of facial swelling generally 2 to 6 weeks after the injury. A case report of a patient with a traumatic pseudoaneurysm of the superficial temporal artery and its management is presented as well as a review of the literature.
CASE REPORT A 75-year-old woman was admitted to the emergency department of our hospital with a 3-cm pulsatile mass in the left temporal region after falling in her home 2 weeks previously (Figure 1). She had already visited another hospital, where arteriography had been performed and had revealed a pseudoaneurysm of the frontal branch of the superficial temporal artery (Figure 2). Instructions to press the afferent end of the artery were given, and a reduction of the mass was controlled periodically in the office. Finally, an excision of the pseudoaneurysm and ligation of the artery was done under local anesthesia and sedation, and the patient was discharged the same day of the surgery with a compressive dressing (Figure 3). The histopathologic findings confirmed a traumatic pseudoaneurysm.
DISCUSSION The first case of a pseudoaneurysm of the superficial temporal artery was published by Bartholin in 1740, and since then more than 400 cases have been reported.1-3 It usually appears after a blunt trauma that occurred a few weeks or months before. Some causes of traumatic temporal artery pseudoaneurysms are caused by contact sports, fall, fistfight, hair transplantation, a
Hospital Clínic de Barcelona. Hospital Sant Joan de Déu, Barcelona. c Hospital Germans Trias i Pujol, Badalona. Received for publication Aug 11, 2013; returned for revision Aug 16, 2013; accepted for publication Aug 21, 2013. Ó 2014 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2013.08.020 b
e112
skin tumor excision, temporal joint surgery, scalp injuries, facelift, parotid surgery, mandibular condylar fracture, or neurosurgical use of cranial halo fixation.1,4-9 Von Willebrand disease may predispose to pseudoaneurysm formation after prolonged bleeding that may damage the vessel wall owing to reduced or dysfunctional von Willebrand factor.10 Because of the etiologic factors, the majority of patients are adults, although a few pediatric cases have been reported.11,12 The superficial temporal artery is the terminal branch of the external carotid and typically has an anterior or frontal branch and a posterior or parietal branch. Although pseudoaneurysms of the facial arteries, internal maxillary arteries, and internal carotid artery have been reported,13-16 the most affected artery is the superficial temporal artery, owing to the superficial course and because it lies directly against the skull in the area between the frontalis and temporalis muscles,2,4 with less protection from trauma. The difference between a true and a false aneurysm (pseudoaneurysm) is the lack of all 3 layers of the arterial wall in a pseudoaneurysm, in comparison with a true aneurysm, which is a dilation of an intact arterial wall. The trauma can cause a disruption of the vessel wall, with extravasation of the blood and formation of a hematoma and pseudocapsule that can expand from the pressure of the blood flow.2-4,9 The clinical examination is very important and reveals a slow-growth pulsatile mass in the temporal area in synchrony with the heartbeat a few weeks after a blunt injury. Other symptoms that can appear are headache, ear pain, facial palsy, or hemorrhage. The volume of the mass and the pulsation can be reduced with local compression.2-4,11,17 Differential diagnosis includes lipoma, hematoma, enlarged lymph node, neuroma, abscess, soft tissue tumor, epidermal inclusion cyst, arteriovenous fistula, intracranial lesions, subdural hematoma, aneurysm of the middle meningeal artery with erosion of the temporal bone, or angiofibroma.1-4
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CASE REPORT Rubio-Palau et al. e113
Fig. 3. Size reduction of the pseudoaneurysm and surgical excision.
Fig. 1. Left superficial temporal artery pseudoaneurysm.
reconstruction of the vessel is not necessary. Other treatment options are embolization (using particles, microcoils, balloons, alcohol, isobutyl-2-cyanoacrylate, and iophendylate) or ultrasound-guided percutaneous thrombin injection.1-4,11,15,17,19
CONCLUSION Traumatic pseudoaneurysm of the superficial temporal artery is an uncommon pathosis usually secondary to blunt trauma. Clinical examination can lead to the diagnosis, and complementary studies such as Doppler ultrasonography, arteriography, or computed tomographic angiography confirm it. The treatment is the surgical resection of the lesion and ligation of the proximal and distal parts of the superficial temporal artery. REFERENCES
Fig. 2. Arteriography showing a left superficial temporal artery pseudoaneurysm.
Diagnostic tests can be used to aid or confirm the diagnosis. Doppler ultrasonography can manifest a vessel dilation with turbulent flow. Arteriography is the diagnostic procedure of choice, but it is an invasive study. A minimally invasive alternative can be computed tomographic angiography. Needle aspiration should be avoided to prevent hemorrhage, which can be difficult to control.2,4,9,11,18 This pathosis must be treated because of the pain, the risk of hemorrhage in case of rupture, the cosmetic defect, and the compression of adjacent structures, and also because it can cause an erosion of the underlying bone of the skull. The treatment of choice is the surgical resection of the pseudoaneurysm and ligation of the proximal and distal vessels under local or general anesthesia. Because of the rich vasculature in this region,
1. Maheshwari R, Paterson AW. Pseudoaneurysm of the superficial temporal artery. Br J Oral Maxillofac Surg. 2009;47:412-413. 2. Mizouni H, et al. Post-traumatic pseudoaneurysm of the superficial temporal artery: a rare cause of facial mass. European Journal of Radiology Extra. 2011;79:e33-e35. 3. Sardana V, et al. Traumatic pseudoaneurysm of the superficial temporal artery: a case report and review of literature. Indian Journal of Neurotrauma. 2012;9:56-58. 4. Evans CC, et al. Traumatic pseudoaneurysm of the superficial temporal artery: two cases and review of the literature. J Am Acad Dermatol. 2003;49(5, suppl):286-288. 5. Li W, Long X, Deng M. Superficial temporal artery pseudoaneurysm: report of a rare case secondary to mandibular condylar fracture. J Craniofac Surg. 2013;24:e360-e361. 6. Woodhouse NR, et al. A rare cause of a parotid mass: spontaneous pseudoaneurysm of the superficial temporal artery. Int J Oral Maxillofac Surg. 2010;39:1234-1236. 7. Bernstein JM, Bury RW, Nigam A. Superficial temporal artery pseudoaneurysm: first reported case after parotid surgery. J Laryngol Otol. 2010;124:441-442. 8. Lin K, et al. Superficial temporal artery pseudoaneurysm after face lift. Aesthet Surg J. 2004;24:28-32. 9. Pourdanesh F, et al. Pseudoaneurysm of the superficial temporal artery following penetrating trauma. J Craniofac Surg. 2013;24: e334-e337. 10. Ricciardo BJ, et al. Von Willebrand disease associated with superficial temporal artery pseudoaneurysm. Eur J Vasc Endovasc Surg. 2005;30:285-287.
ORAL AND MAXILLOFACIAL SURGERY e114 Rubio-Palau et al. 11. Quereshy FA, Choi S, Buma B. Traumatic pseudoaneurysm of the superficial temporal artery in a pediatric patient: a case report. J Oral Maxillofac Surg. 2008;66:133-135. 12. Ahn HS, et al. Traumatic pseudoaneurysm of the superficial temporal artery in a child: a case report. Childs Nerv Syst. 2010;26:117-120. 13. Dediol E, et al. Facial artery pseudoaneurysm without evidence of trauma. Int J Oral Maxillofac Surg. 2011;40:988-990. 14. Dediol E. Pseudoaneurysm of the facial artery as a complication of the sagittal split osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110:683. 15. Pinjala RK, Joshi S, Rammurti S. Traumatic pseudoaneurysm of the internal maxillary artery. EJVES Extra. 2007;14:54-55. 16. Ichihashi T, Matsushita Y, Tsuji Y, Harano H, Nakagawa H. [A case of treatment on traumatic pseudoaneurysm of internal carotid artery occurred epistaxis]. No To Shinkei. 2003;55:367-372 [in Japanese].
OOOO February 2014 17. Fukunaga N, et al. Traumatic pseudoaneurysm of superficial temporal artery. Am J Surg. 2010;199:e1-e2. 18. Goksu E, Senay E, Alimoglu E, Aksoy C. Superficial temporal artery pseudoaneurysm: ultrasonographic diagnosis in the ED. Am J Emerg Med. 2009;27:627.e1-627.e3. 19. Hong JT, et al. Traumatic pseudoaneurysm of the superficial temporal artery treated by endovascular coil embolization. Surg Neurol. 2006;66:86-88. Reprint requests: Josep Rubio-Palau Hospital Clínic de Barcelona C/ Villarroel 170 08036 Barcelona Spain [email protected]
Traumatic pseudoaneurysm of the superficial temporal artery: case report and review of the literature Josep Rubio-Palau, MD, DDS,a Ada Ferrer-Fuertes, MD,a Eloy García-Díez, MD,b Jordi Garcia-Linares, MD, DDS, PhD,c Carles Martí-Pagès, MD, PhD,a and Ramón Sieira-Gil, MDa Hospital Clínic de Barcelona and Hospital Sant Joan de Déu, Barcelona, and Hospital Germans Trias i Pujol, Badalona, Spain
Pseudoaneurysm of the superficial temporal artery is an uncommon complication of a blunt trauma. It usually presents as a pulsating mass in the frontotemporal area a few weeks after the injury. Doppler ultrasonography, angiography, or computed tomographic angiography can aid or confirm the diagnosis. The treatment of choice is the surgical resection of the pseudoaneurysm and ligation of the vessels. We report a case of a pseudoaneurysm of the frontal branch of the superficial temporal artery and review the literature. (Oral Surg Oral Med Oral Pathol Oral Radiol 2014;117:e112-e114)
Pseudoaneurysm is the result of total or partial rupture of the arterial wall, usually after a blunt trauma, with the formation of a hematoma and organization. Its occurrence in the superficial temporal artery is a rare cause of facial swelling generally 2 to 6 weeks after the injury. A case report of a patient with a traumatic pseudoaneurysm of the superficial temporal artery and its management is presented as well as a review of the literature.
CASE REPORT A 75-year-old woman was admitted to the emergency department of our hospital with a 3-cm pulsatile mass in the left temporal region after falling in her home 2 weeks previously (Figure 1). She had already visited another hospital, where arteriography had been performed and had revealed a pseudoaneurysm of the frontal branch of the superficial temporal artery (Figure 2). Instructions to press the afferent end of the artery were given, and a reduction of the mass was controlled periodically in the office. Finally, an excision of the pseudoaneurysm and ligation of the artery was done under local anesthesia and sedation, and the patient was discharged the same day of the surgery with a compressive dressing (Figure 3). The histopathologic findings confirmed a traumatic pseudoaneurysm.
DISCUSSION The first case of a pseudoaneurysm of the superficial temporal artery was published by Bartholin in 1740, and since then more than 400 cases have been reported.1-3 It usually appears after a blunt trauma that occurred a few weeks or months before. Some causes of traumatic temporal artery pseudoaneurysms are caused by contact sports, fall, fistfight, hair transplantation, a
Hospital Clínic de Barcelona. Hospital Sant Joan de Déu, Barcelona. c Hospital Germans Trias i Pujol, Badalona. Received for publication Aug 11, 2013; returned for revision Aug 16, 2013; accepted for publication Aug 21, 2013. Ó 2014 Elsevier Inc. All rights reserved. 2212-4403/$ - see front matter http://dx.doi.org/10.1016/j.oooo.2013.08.020 b
e112
skin tumor excision, temporal joint surgery, scalp injuries, facelift, parotid surgery, mandibular condylar fracture, or neurosurgical use of cranial halo fixation.1,4-9 Von Willebrand disease may predispose to pseudoaneurysm formation after prolonged bleeding that may damage the vessel wall owing to reduced or dysfunctional von Willebrand factor.10 Because of the etiologic factors, the majority of patients are adults, although a few pediatric cases have been reported.11,12 The superficial temporal artery is the terminal branch of the external carotid and typically has an anterior or frontal branch and a posterior or parietal branch. Although pseudoaneurysms of the facial arteries, internal maxillary arteries, and internal carotid artery have been reported,13-16 the most affected artery is the superficial temporal artery, owing to the superficial course and because it lies directly against the skull in the area between the frontalis and temporalis muscles,2,4 with less protection from trauma. The difference between a true and a false aneurysm (pseudoaneurysm) is the lack of all 3 layers of the arterial wall in a pseudoaneurysm, in comparison with a true aneurysm, which is a dilation of an intact arterial wall. The trauma can cause a disruption of the vessel wall, with extravasation of the blood and formation of a hematoma and pseudocapsule that can expand from the pressure of the blood flow.2-4,9 The clinical examination is very important and reveals a slow-growth pulsatile mass in the temporal area in synchrony with the heartbeat a few weeks after a blunt injury. Other symptoms that can appear are headache, ear pain, facial palsy, or hemorrhage. The volume of the mass and the pulsation can be reduced with local compression.2-4,11,17 Differential diagnosis includes lipoma, hematoma, enlarged lymph node, neuroma, abscess, soft tissue tumor, epidermal inclusion cyst, arteriovenous fistula, intracranial lesions, subdural hematoma, aneurysm of the middle meningeal artery with erosion of the temporal bone, or angiofibroma.1-4
OOOO Volume 117, Number 2
CASE REPORT Rubio-Palau et al. e113
Fig. 3. Size reduction of the pseudoaneurysm and surgical excision.
Fig. 1. Left superficial temporal artery pseudoaneurysm.
reconstruction of the vessel is not necessary. Other treatment options are embolization (using particles, microcoils, balloons, alcohol, isobutyl-2-cyanoacrylate, and iophendylate) or ultrasound-guided percutaneous thrombin injection.1-4,11,15,17,19
CONCLUSION Traumatic pseudoaneurysm of the superficial temporal artery is an uncommon pathosis usually secondary to blunt trauma. Clinical examination can lead to the diagnosis, and complementary studies such as Doppler ultrasonography, arteriography, or computed tomographic angiography confirm it. The treatment is the surgical resection of the lesion and ligation of the proximal and distal parts of the superficial temporal artery. REFERENCES
Fig. 2. Arteriography showing a left superficial temporal artery pseudoaneurysm.
Diagnostic tests can be used to aid or confirm the diagnosis. Doppler ultrasonography can manifest a vessel dilation with turbulent flow. Arteriography is the diagnostic procedure of choice, but it is an invasive study. A minimally invasive alternative can be computed tomographic angiography. Needle aspiration should be avoided to prevent hemorrhage, which can be difficult to control.2,4,9,11,18 This pathosis must be treated because of the pain, the risk of hemorrhage in case of rupture, the cosmetic defect, and the compression of adjacent structures, and also because it can cause an erosion of the underlying bone of the skull. The treatment of choice is the surgical resection of the pseudoaneurysm and ligation of the proximal and distal vessels under local or general anesthesia. Because of the rich vasculature in this region,
1. Maheshwari R, Paterson AW. Pseudoaneurysm of the superficial temporal artery. Br J Oral Maxillofac Surg. 2009;47:412-413. 2. Mizouni H, et al. Post-traumatic pseudoaneurysm of the superficial temporal artery: a rare cause of facial mass. European Journal of Radiology Extra. 2011;79:e33-e35. 3. Sardana V, et al. Traumatic pseudoaneurysm of the superficial temporal artery: a case report and review of literature. Indian Journal of Neurotrauma. 2012;9:56-58. 4. Evans CC, et al. Traumatic pseudoaneurysm of the superficial temporal artery: two cases and review of the literature. J Am Acad Dermatol. 2003;49(5, suppl):286-288. 5. Li W, Long X, Deng M. Superficial temporal artery pseudoaneurysm: report of a rare case secondary to mandibular condylar fracture. J Craniofac Surg. 2013;24:e360-e361. 6. Woodhouse NR, et al. A rare cause of a parotid mass: spontaneous pseudoaneurysm of the superficial temporal artery. Int J Oral Maxillofac Surg. 2010;39:1234-1236. 7. Bernstein JM, Bury RW, Nigam A. Superficial temporal artery pseudoaneurysm: first reported case after parotid surgery. J Laryngol Otol. 2010;124:441-442. 8. Lin K, et al. Superficial temporal artery pseudoaneurysm after face lift. Aesthet Surg J. 2004;24:28-32. 9. Pourdanesh F, et al. Pseudoaneurysm of the superficial temporal artery following penetrating trauma. J Craniofac Surg. 2013;24: e334-e337. 10. Ricciardo BJ, et al. Von Willebrand disease associated with superficial temporal artery pseudoaneurysm. Eur J Vasc Endovasc Surg. 2005;30:285-287.
ORAL AND MAXILLOFACIAL SURGERY e114 Rubio-Palau et al. 11. Quereshy FA, Choi S, Buma B. Traumatic pseudoaneurysm of the superficial temporal artery in a pediatric patient: a case report. J Oral Maxillofac Surg. 2008;66:133-135. 12. Ahn HS, et al. Traumatic pseudoaneurysm of the superficial temporal artery in a child: a case report. Childs Nerv Syst. 2010;26:117-120. 13. Dediol E, et al. Facial artery pseudoaneurysm without evidence of trauma. Int J Oral Maxillofac Surg. 2011;40:988-990. 14. Dediol E. Pseudoaneurysm of the facial artery as a complication of the sagittal split osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110:683. 15. Pinjala RK, Joshi S, Rammurti S. Traumatic pseudoaneurysm of the internal maxillary artery. EJVES Extra. 2007;14:54-55. 16. Ichihashi T, Matsushita Y, Tsuji Y, Harano H, Nakagawa H. [A case of treatment on traumatic pseudoaneurysm of internal carotid artery occurred epistaxis]. No To Shinkei. 2003;55:367-372 [in Japanese].
OOOO February 2014 17. Fukunaga N, et al. Traumatic pseudoaneurysm of superficial temporal artery. Am J Surg. 2010;199:e1-e2. 18. Goksu E, Senay E, Alimoglu E, Aksoy C. Superficial temporal artery pseudoaneurysm: ultrasonographic diagnosis in the ED. Am J Emerg Med. 2009;27:627.e1-627.e3. 19. Hong JT, et al. Traumatic pseudoaneurysm of the superficial temporal artery treated by endovascular coil embolization. Surg Neurol. 2006;66:86-88. Reprint requests: Josep Rubio-Palau Hospital Clínic de Barcelona C/ Villarroel 170 08036 Barcelona Spain [email protected]
