Superficial Temporal Artery Pseudoaneurysm Treated with Manual Compression Alone
Jong-Hoon Kim, Young-Jin Jung, Chul-Hoon Chang
Department of Neurosurgery, Yeungnam University School of Medicine, Daegu, Korea
Traumatic pseudoaneurysm of the superficial temporal artery (STA) is an uncommon lesion and resection of the lesion is the treatment of choice.
Three patients with traumatic pseudoaneurysm of the STA treated with only manual compression of the lesions were examined for this study.
We report on an effective and safe minimally invasive technique for treat- ment of traumatic pseudoaneurysm of the STA.
J Cerebrovasc Endovasc Neurosurg.
2015 March;17(1):49-53 Received : 2 December 2014 Revised : 8 January 2015 Accepted : 11 March 2015
Correspondence to Chul-Hoon Chang Department of Neurosurgery, Yeungnam Univer- sity Medical Center, Yeungnam University School of Medicine, 170 Hyeonchung-ro, Nam-gu, 705-703 Daegu, Korea
Tel : 82-53-620-3790, 3795 Fax : 82-53-620-3770 E-mail : [email protected]
ORCID : http://orcid.org/0000-0001-5909-6535 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/li- censes/by-nc/3.0) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords Pseudoaneurysm, Superficial temporal artery, Scalp
INTRODUCTION
Traumatic superficial temporal artery (STA) pseu- doaneurysm is an uncommon lesion.2)7) There are sev- eral treatment options for this type of lesion, includ- ing ligation of afferent and efferent vessels, resection of the pseudoaneurysm, and embolization of the proximal STA,8)12) however, conservative treatment is not recommended for various reasons8) that will be covered in this study. We report on three cases of traumatic STA pseudoaneurysm treated by simple manual compression of the proximal portion of the af- ferent artery and discuss the treatment options.
CASE REPORTS
Case 1
A 33-year-old man presented with a pulsating mass above his left eyebrow resulting from a collision
with a cupboard. Before that, he'd had a large, pulsat- ing mass on his frontal scalp for the past 13 years.
The old frontal mass measured 4 × 3 cm in diameter, and the new one measured 1.5 × 1.5 cm in diameter.
Both lesions had easily palpable thrills and audible bruit. Magnetic resonance imaging study showed many flow signal voids and a nidus in the subgaleal space.
There were no abnormal lesions in the intracranial space. Digital subtraction angiograms (DSA) showed scalp arteriovenous malformation (AVM) with a huge nidus supplied by feeders from the frontal and parie- tal branches of the right STA and the frontal branch of the left STA. Another new finding was a small aneurysm supplied by the left STA (Fig. 1A). The ve- nous drainage occurred through an enlarged super- ficial scalp vein and supraorbital vein. We supposed that by removing the large AVM, the left STA flow would be reduced, and we expected that the pseudoa- neurysm will eventually disappear as a result of natu-
A B C
Fig. 1. (A) The lateral view of the selective external carotid artery angiography shows a pseudoaneurysm (arrow) with an arteriovenous malformation (AVM) (arrow heads). (B) The AVM was resected surgically. Manual compression was performed in just the proximal por- tion of the neck of the pseudoaneurysm. On the follow-up angiography five days after surgery with manual compression of the feed- ing artery, the AVM nidus and pseudoaneurysm had disappeared (arrow). (C) The gross finding showed a well-demarcated gray, rub- bery mass (1.0 g, 1.5 x 1.2 cm). On section, the cut surface showed a cystic lesion filled with a dark-brown blood clot.
rally occurring spontaneous thrombosis. With this goal in mind, we planned a resection of only the larg- er scalp AVM.
The scalp was dissected with a bifrontal skin-incision.
An orifice of the frontal branch of the bilateral super- ficial temporal artery in the nidus was exposed. By exfoliating the nidus from the periosteum, both feeding arteries were clipped. After confirming that pulsation of the AVM nidus had subsided, numerous drainage veins were coagulated and the AVM nidus was com- pletely removed. Then, manual compression was per- formed in just the proximal portion of the neck of the pseudoaneurysm. Compression time of the feeding ar- tery was approximately 30-40 minutes because we continued compression until pulsating flow had com- pletely disappeared. On follow-up DSA five days af- ter surgery, the AVM nidus and the left frontal pseu- doaneurysm had disappeared (Fig. 1B), and the small pseudoaneurysm on his left eyebrow had converted into a completely thrombosed mass lesion.
Without interval change, the palpable left frontal mass (thrombosed pseudoaneurysm) was still present at the seven-week follow-up visit. Resection of this le- sion had been performed by a plastic surgeon because of cosmetic problems. The gross findings showed a well-demarcated, gray, rubbery mass (1.0 g, 1.5 × 1.2
cm). When viewed in section, the cut surface showed a cystic lesion filled with a dark brown blood clot (Fig, 1C). Biopsy results indicated a dilated blood vessel with thrombus and papillary endothelial hyperplasia.
Case 2
A 56-year-old woman presented with subarachnoid hemorrhage due to a ruptured right middle cerebral artery aneurysm. The patient's Hunt and Hess grade was 3, and her Fisher grade was also 3. Three-dimen- sional computed tomography (3-D CT) angiography confirmed an aneurysm at the right middle cerebral artery bifurcation. The patient was immediately taken into surgery (Right fronto-temporal craniotomy and clipping the neck of the ruptured aneurysm).
Two weeks after surgery, a DSA showed an aneur- ysmal dilatation at the parietal division of the right superficial temporal artery. On physical examination, a pulsatile mass measuring 1 × 1 cm, which was soft and easily compressible with digital pressure, was visi- ble on the left temporal region. This was the head-pin fixation site from the previous aneurysm surgery. After manual compression of just the proximal afferent vessel, the pulsating mass was converted to a thrombosed mass. Three-dimensional computed tomography an- giography showed absence of internal blood flow in the aneurysm.
A B C
D E
Fig. 2. (A) A 1 x 1.5 cm pulsatile mass was visible on the right parietal region. (B) Doppler sonography showed swirling arterial blood-flow in the pulsatile mass. (C) Pre compression-treatment three-dimensional computed tomographic (3-D CT) angiogram shows a pseudoaneurysm with flow to the underlying artery. (D) After manual compression, the pseudoaneurysm was filled with thrombus, and there was no arterial blood flow in the lesion. (E) Post compression-treatment 3-D CT angiogram shows obliteration of the pseudoaneurysm.
Case 3
A 14-year-old male presented with a pulsatile mass on his right parietal area. Four weeks ago, he had been hit on the head with a bat. A pulsatile mass measuring 1 × 1.5 cm, which was easily compressible with digital pressure, was visible on the right tempo- ral region (Fig. 2A). Preoperative color Doppler so- nography showed arterial blood flow in the pulsatile mass, and 3-D CT angiography showed an aneur- ysmal sac at the parietal branch of the STA (Fig. 2B, C). The pulsation in the mass disappeared by prox-
imal compression of the afferent artery.
On postoperative color Doppler sonography after manual compression, the pseudoaneurysm was filled with thrombus and there was no arterial blood flow in the lesion (Fig. 2D). Post compression-treatment 3-D CT angiography showed complete obliteration of the pseudoaneurysm (Fig. 2E).
DISCUSSION
The STA pseudoaneurysm is uncommon, and only
400 cases have been reported in medical literature.2)7) More than 95% of pseudoaneurysms are traumatic in origin.
Numerous iatrogenic aneurysms have been reported after arterial catheterization, temporomandibular ar- throplasty, hair transplantation, cyst removal, place- ment of external ventricular-drainage catheters, cra- niotomy, superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis, and Gardner traction.6)9) Because of its anatomic location, the STA is the most frequent site of traumatic pseudoaneurysm on the face.6) In its superficial tract, the temporalis muscle is the only protective tissue between the STA and the outer table of the skull.6) Most STA pseudoaneurysms involve the anterior branch because of the lack of cushioning effect where the artery crosses from the temporalis to the frontalis muscle and because of the tethering effect of the fascia at this level, which limits any lateral displacement of the artery in response to tangential forces.11) For this reason, most STA aneur- ysms are false aneurysms (pseudoaneurysms), defined by lack of dilation in all 3 layers of the arterial wall.8) Usually, there is partial transection or traumatic ne- crosis of part of the vessel wall, and the resultant hemorrhage into the vessel wall is contained by the skin.5) A hematoma forms, and slowly expands from the pressure exerted by local blood-flow. This slow expansion explains the frequently reported 1-6 weeks between the traumatic event and onset of the mass.10)
Treatment is required for superficial temporal artery pseudoaneurysms due to the risk of spontaneous rup- ture, pain, tenderness, bony erosion and cosmetic dis- figuration in the patient.3) The standard treatment is ligation of the afferent and efferent vessels followed by excision under local anesthesia.4)8)12)
Until recently, manual compression was the treat- ment of choice for pseudoaneurysm at the femoral artery.1) Like femoral pseudoaneurysms, STA pseu- doaneurysms are located superficially, and the tempo- ral bone is located just below the lesion. Compression can be performed and is convenient in this situation.
In the examples covered in this paper, gradual pres-
sure was applied with the thumb of the practitioner to obliterate blood flow in the neck and cause throm- bosis formation. Compression was done just proximal to the neck of the pseudoaneurysm. Compression time of the feeding artery was approximately 30-40 minutes because we continued compression until pul- sating flow had disappeared. This technique is very simple, safe, and easy. Thus, it might be a good treat- ment option before resorting to surgical intervention.
This treatment method may have some limitations.
First, we had no experience in the lesion that is too large for manual compression, when it causes severe mass effects such as intractable headaches, bone ero- sion, and in infectious condition. Second, as shown in the first case, because the thrombosed mass scar does not disappear for a long period of time, cosmetic problems may occur.
CONCLUSION
Pulsatile lesions that are continuous with an STA with a history of trauma should be considered STA pseudoaneurysms. 3-D CT angiography and color Doppler sonography are convenient and noninvasive modalities for use in diagnosis of this lesion and in decisions regarding post-treatment follow up. Surgical excision is generally the standard treatment. However, if the pseudoaneurysm is small, flow reduction by manual compression of the proximal portion of the aneurysmal sac and induced spontaneous thrombosis might be an effective and minimally invasive treat- ment option.
Disclosure
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
REFERENCES
1. Ahmad F, Turner SA, Torrie P, Gibson M. Iatrogenic femoral artery pseudoaneurysms-a review of current
methods of diagnosis and treatment. Clin Radiol. 2008 Dec;63(12):1310-6.
2. Conner WC 3rd, Rohrich RJ, Pollock RA. Traumatic aneurysms of the face and temple: a patient report and literature review, 1644 to 1998. Ann Plast Surg. 1998 Sep;41(3):321-6.
3. Cremone JC, Grosh JD. Traumatic aneurysms of the su- perficial temporal artery. J Trauma. 1980 Nov;20(11):986-8.
4. Evans CC, Larson MJ, Eichhorn PJ, Taylor RS. Traumatic pseudoaneurysm of the superficial temporal artery: two cases and review of the literature. J Am Acad Dermatol.
2003 Nov;49(5 Suppl):S286-8.
5. Fox AJ, Viñuela F, Pelz DM, Peerless SJ, Ferguson GG, Drake CG, et al. Use of detachable balloons for prox- imal artery occlusion in the treatment of unclippable cerebral aneurysms. J Neurosurg. 1987 Jan;66(1):40-6.
6. Grasso RF, Quattrocchi CC, Crucitti P, Carboni G, Coppola R, Zobel BB. Superficial temporal artery pseudoaneur- ysm: a conservative approach in a critically ill patient.
Cardiovasc Intervent Radiol. 2007 Mar-Apr;30(2):286-8.
7. Han MH, Sung MW, Chang KH, Min YG, Han DH, Han MC. Traumatic pseudoaneurysm of the intracavernous ICA presenting with massive epistaxis: imaging diagnosis
and endovascular treatment. Laryngoscope. 1994 Mar;104 (3 Pt 1):370-7.
8. Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg. 1991 Mar;13(3):452-8.
9. Lee DH, Hur SH, Choi SJ, Jung SM, Ryu DS, Park MS, et al. A recurred carotid siphon pseudoaneurysm after detachable coil embolization successful endovascular management with detachable balloons. Interv Neuroradiol.
2002 Mar;8(1):61-5.
10. Mattens M, Hessmann M, Lesceu O, Rumbaut J.
Traumatic false aneurysm of the superficial temporal artery. Acta Chir Belg. 1992 Jul-Aug;92(4):201-3.
11. Pipinos, II, Dossa CD, Reddy DJ. Superficial temporal artery aneurysms. J Vasc Surg. 1998 Feb;27(2):374-7.
12. Quereshy FA, Choi S, Buma B. Traumatic pseudoaneur- ysm of the superficial temporal artery in a pediatric patient:
a case report. J Oral Maxillofac Surg. 2008 Jan;66(1):133-5.
