Traumatic Middle Meningeal Artery Pseudoaneurysm Managed With Preoperative Glue Embolization Followed by Decompressive Craniectomy: A Case Report

Abstract

Traumatic pseudoaneurysm of the middle meningeal artery (MMA) is a rare but potentially life-threatening condition, typically resulting from a laceration of the arterial wall due to adjacent skull fractures. We report an unusual case of a traumatic MMA pseudoaneurysm presenting with a large intracerebral hemorrhage (ICH) and significant subfalcine herniation that was successfully treated with preoperative glue embolization followed by decompressive craniectomy. This case emphasizes the importance of early vascular evaluation in traumatic ICH and highlights the value of endovascular embolization for achieving hemostatic control prior to surgery.

INTRODUCTION

Traumatic pseudoaneurysm of the middle meningeal artery (MMA) is an uncommon vascular lesion, typically arising from blunt head trauma with skull fracture involving the temporal base. Although rare, rupture of such pseudoaneurysms may cause life-threatening intracranial hemorrhage or uncontrolled intraoperative bleeding.

Conventional digital subtraction angiography (DSA) has been the gold standard for diagnosis, but computed tomography angiography (CTA) offers a rapid and noninvasive alternative in emergency trauma settings. We describe a case of traumatic intracerebral hemorrhage (T-ICH) associated with temporal bone fracture in which CTA identified an MMA pseudoaneurysm, successfully treated with glue embolization prior to decompressive craniectomy.

CASE REPORT

A 61-year-old male was found collapsed at home with semicomatous mentality and brought to the emergency department at 14:10. Brain computed tomography demonstrated a large left temporal intracerebral hemorrhage (ICH) measuring approximately 150 mL (calculated using the JLK AI volumetric program), with a 13-mm midline shift and temporal bone fracture extending to the zygomatic arch root (FIGURE 1).

FIGURE 1. Initial brain computed tomography showing a large traumatic intracerebral hemorrhage (T-ICH) in the left fronto-temporo-parietal region with significant midline shift, associated with a left temporal bone fracture (arrow).

CTA was performed to evaluate possible vascular injury as a potential cause of ICH and to assess associated skull fractures. CTA revealed a pseudoaneurysm arising from the frontal branch of the left MMA, slightly distal to its bifurcation (FIGURE 2). The lesion measured approximately 8.9 mm in diameter and demonstrated an irregular shape with delayed contrast stagnation, consistent with a traumatic pseudoaneurysm (FIGURE 3).

FIGURE 2. Brain computed tomography angiography demonstrating (arrow) an aneurysmal formation at the skull base, suggestive of a vascular lesion.

FIGURE 3. Transfemoral cerebral angiography showing a pseudoaneurysm (arrow) arising from the middle meningeal artery, a branch of the external carotid artery.

Cerebral angiography began at 15:30 under general anesthesia. Angiography was performed via the right common femoral artery using a 7-Fr Terumo sheath. A 6-Fr Chaperon guiding catheter (MicroVention, Tustin, CA, USA) was placed in the left external carotid artery. Superselective catheterization of the pseudoaneurysm was achieved using a microcatheter, and glue embolization was performed with 0.5 mL of Histoacryl (B. Braun, Melsungen, Germany) mixed with 5 mL of Lipiodol (Guerbet, Villepinte, France) (FIGURE 4).

FIGURE 4. Intra-procedural angiographic image during glue embolization of the middle meningeal artery pseudoaneurysm (arrow). The embolic material is being injected through the microcatheter to occlude the pseudoaneurysm sac.

Although surgical exposure of the pseudoaneurysm through skull base dissection could have been considered, this approach may be technically demanding and time-consuming for neurosurgeons without extensive skull base experience. Furthermore, deep dissection toward the skull base carries the potential risk of uncontrolled intraoperative rebleeding. Therefore, glue embolization was performed first, as it allows rapid and effective control of the bleeding focus within a relatively short procedure time before proceeding to decompressive craniectomy.

Decompressive craniectomy was initiated at 15:55. Intraoperatively, a small subdural hematoma was observed, but the main lesion was a large ICH. The pseudoaneurysm was located within the hematoma margin, confirming that the ICH resulted from pseudoaneurysm rupture. No significant epidural hematoma was identified, and approximately 400 mL of packed red blood cells were transfused during the operation (FIGURE 5).

FIGURE 5. Postoperative computed tomography scan after decompressive craniectomy showing hematoma evacuation without evidence of rebleeding.

The patient was transferred to a rehabilitation hospital in deep drowsy mentality with stable vital signs.

DISCUSSION

Traumatic pseudoaneurysms of the MMA account for less than 1% of vascular lesions associated with head trauma.¹⁾ They usually result from laceration of the arterial wall by adjacent skull fractures, particularly at the temporal base. Clinical manifestations vary, but patients may present with delayed or recurrent hematomas, or experience massive intraoperative bleeding if the lesion is unrecognized.²⁾

In this case, temporal bone fracture and a large T-ICH prompted CTA evaluation. Although DSA remains the diagnostic gold standard, CTA provided a rapid and accurate diagnosis of the pseudoaneurysm, which was subsequently confirmed on transfemoral cerebral angiography. Preoperative glue embolization secured the lesion and allowed safe craniectomy. Without this step, uncontrolled bleeding from the skull base pseudoaneurysm could have led to prolonged surgery and unfavorable outcome.

This case emphasizes the importance of considering vascular injury in patients with T-ICH and skull base fractures.⁶⁾ CTA should be considered as a screening tool in such cases, and prompt endovascular treatment can significantly improve surgical safety and outcomes.

Endovascular embolization provides rapid and effective bleeding control with minimal surgical risk.⁵⁾ For neurosurgeons without extensive skull base experience, deep dissection may result in major blood loss or uncontrolled rebleeding. Pre-craniectomy glue embolization allows early hemostasis and stabilizes the surgical field, minimizing intraoperative risk.

In previously published cases, such as Mohammed et al.⁴⁾ and Lu and Zhang,³⁾ preoperative embolization was effective for pseudoaneurysm management; however, none of these reports described cases accompanied by significant subfalcine herniation. Our case highlights the clinical importance of rapid identification and embolization in patients with large T-ICH and skull base fractures.

CONCLUSION

Preoperative recognition and embolization of a traumatic MMA pseudoaneurysm prevented catastrophic intraoperative hemorrhage and enabled safe decompressive craniectomy. Although the patient’s neurological recovery was limited to a deep drowsy state, he remained hemodynamically stable. This case underscores the importance of considering vascular injury in patients with traumatic brain injury and highlights the role of preoperative angiographic evaluation and endovascular treatment in improving surgical safety.