J Cerebrovasc Endovasc Neurosurg > Volume 17(1); 2015 > Article
Kim, Jung, and Chang: Superficial Temporal Artery Pseudoaneurysm Treated with Manual Compression Alone

Abstract

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.

INTRODUCTION

Traumatic superficial temporal artery (STA) pseudoaneurysm is an uncommon lesion.2)7) There are several treatment options for this type of lesion, including 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 afferent 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, 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 (Fig. 1A). The venous drainage occurred through an enlarged superficial 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 pseudoaneurysm will eventually disappear as a result of naturally occurring spontaneous thrombosis. With this goal in mind, we planned a resection of only the larger scalp AVM.
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 (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 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 (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-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.

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 temporal region (Fig. 2A). Preoperative color Doppler sonography showed arterial blood flow in the pulsatile mass, and 3-D CT angiography showed an aneurysmal sac at the parietal branch of the STA (Fig. 2B, C). The pulsation in the mass disappeared by proximal 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 arthroplasty, hair transplantation, cyst removal, placement of external ventricular-drainage catheters, craniotomy, 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 aneurysms 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 necrosis 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 rupture, pain, tenderness, bony erosion and cosmetic disfiguration 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 treatment of choice for pseudoaneurysm at the femoral artery.1) Like femoral pseudoaneurysms, STA pseudoaneurysms are located superficially, and the temporal 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 pressure was applied with the thumb of the practitioner to obliterate blood flow in the neck and cause thrombosis 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 pulsating flow had disappeared. This technique is very simple, safe, and easy. Thus, it might be a good treatment 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 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.

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 treatment option.

NOTES

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

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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 portion of the neck of the pseudoaneurysm. On the follow-up angiography five days after surgery with manual compression of the feeding artery, the AVM nidus and pseudoaneurysm had disappeared (arrow). (C) The gross finding showed a well-demarcated gray, rubbery mass (1.0 g, 1.5 × 1.2 cm). On section, the cut surface showed a cystic lesion filled with a dark-brown blood clot.

jcen-17-49-g001.jpg
Fig. 2

(A) A 1 × 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.

jcen-17-49-g002.jpg


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