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 treatment of traumatic pseudoaneurysm of the STA.
Traumatic superficial temporal artery (STA) pseudoaneurysm is an uncommon lesion.
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, pulsating 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 parietal 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 (
The scalp was dissected with a bifrontal skin-incision. An orifice of the frontal branch of the bilateral superficial 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 completely removed. Then, manual compression was performed in just the proximal portion of the neck of the pseudoaneurysm. Compression time of the feeding artery was approximately 30-40 minutes because we continued compression until pulsating flow had completely disappeared. On follow-up DSA five days after surgery, the AVM nidus and the left frontal pseudoaneurysm had disappeared (
Without interval change, the palpable left frontal mass (thrombosed pseudoaneurysm) was still present at the seven-week follow-up visit. Resection of this lesion 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 (
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-dimensional 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 aneurysmal 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 visible 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 angiography showed absence of internal blood flow in the aneurysm.
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 temporal region (
On postoperative color Doppler sonography after manual compression, the pseudoaneurysm was filled with thrombus and there was no arterial blood flow in the lesion (
The STA pseudoaneurysm is uncommon, and only 400 cases have been reported in medical literature.
Numerous iatrogenic aneurysms have been reported after arterial catheterization, temporomandibular arthroplasty, hair transplantation, cyst removal, placement of external ventricular-drainage catheters, craniotomy, superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis, and Gardner traction.
Treatment is required for superficial temporal artery pseudoaneurysms due to the risk of spontaneous rupture, pain, tenderness, bony erosion and cosmetic disfiguration in the patient.
Until recently, manual compression was the treatment of choice for pseudoaneurysm at the femoral artery.
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 erosion, 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.
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 treatment option.