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Traumatic Superficial Temporal Artery Pseudoaneurysm in a Helmeted Lacrosse Player

Tracy, Aaron MHMS1; Klinge, Petra MD, PhD2; Morrison, John MD2; Jayaraman, Mahesh V. MD3; Kriz, Peter K. MD4,5

doi: 10.1249/JSR.0000000000000218
Head, Neck, and Spine: Case Reports
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1Sackler School of Medicine, Tel Aviv, Israel; 2Department of Neurosurgery, Rhode Island Hospital/Hasbro Children’s Hospital, Warren Alpert Medical School, Brown University, Providence, RI; 3Department of Diagnostic Imaging, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, RI; 4Department of Orthopedics, Rhode Island Hospital/Hasbro Children’s Hospital, Warren Alpert Medical School, Brown University, Providence, RI; 5Department of Pediatrics, Rhode Island Hospital/Hasbro Children’s Hospital, Warren Alpert Medical School, Brown University, Providence, RI

Address for correspondence: Peter K. Kriz, MD, 2 Dudley St, Suite 200, Providence, RI 02905; E-mail: Peter_Kriz@brown.edu.

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Introduction

Superficial temporal artery pseudoaneurysms (STAP) are uncommon vascular lesions typically coinciding with blunt head trauma. Although hundreds of cases have been described (5,10), few have been reported in sports medicine journals. Diagnosis of STAP can be made clinically, presenting as painless masses at the site of injury. STAP can be confused with cysts, abscesses, hematomas, lipomas, and other dermal lesions (2) but can be primarily identified using duplex ultrasound (US) or computed tomography angiography (CTA). Point-of-care musculoskeletal US, a modality becoming more widely available in sports medicine clinics, provides safe and accurate diagnosis of STAP and can facilitate referral, treatment, and ultimately return to play for athletes (10). Timely diagnosis is critical as pseudoaneurysm rupture is the main cause of morbidity. We present the case of a 16-year-old high school lacrosse player who developed STAP after being struck by a lacrosse ball.

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Case Report

A 16-year old teenage boy presented to our sports medicine clinic with a painless left frontotemporal subcutaneous mass. Four weeks prior, he was struck in his helmeted head by a lacrosse ball from a close-range shot. He developed an area of swelling and discoloration over the left forehead 10 to 15 min after impact. He did not experience any headache, dizziness, or light/noise sensitivity postinjury. Initially, his lesion was managed as a scalp hematoma, and conservative treatment consisting of ice and compression was recommended. His athletic trainer referred him after his lesion failed to resolve clinically. Examination showed a 1-cm × 1-cm mobile, firm, rubbery mass in the subcutaneous tissue overlying the left forehead (Fig. 1A). The mass was nontender and pulsatile, with no appreciable underlying bony step-off. No bruising or hyperpigmentation was seen. The patient was neurologically stable.

Figure 1

Figure 1

Doppler US identified a hypoechogenic, pulsatile structure in the subgaleal soft tissue, whereas color Doppler displayed appreciable venous and arterial flow through the structure (Fig. 1B,C). CTA was recommended to allow assessment of both soft tissue and bony pathology given the traumatic nature of the injury. CTA confirmed a pseudoaneurysm of the frontal branch of the left superficial temporal artery (STA).

Surgical exploration was performed. The course of the proximal STA branch feeding the aneurysm was identified using US. Proximal control of the STA was obtained in the subgaleal plane, and the pseudoaneurysm was identified as located in the galeal layer (Fig. 2A). Proximal and distal feeders were ligated and microsurgical resection of the aneurysm was accomplished (Fig. 2B). Histology confirmed a pseudoaneurysm with mural hemorrhages and proliferating inflammatory granulation tissue with hemosiderin deposits and a luminal thrombus. At 1-month follow-up, the athlete was cleared to return to collision sports.

Figure 2

Figure 2

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Discussion

STAP remains the most common type of craniofacial traumatic aneurysms (8). Thomas Bartholin first documented a STAP lesion secondary to blunt trauma in 1644 (5). Subsequently, nearly 400 STAP cases have been reported (10). Since 1994, STAP has been reported with increasing frequency in sports (9). Most incidental causes involve a high-speed projectile that imparts a blow to the athlete’s temporal fossa. To our knowledge, this is the first case report of STAP in a lacrosse player and one of few sport-related cases involving a helmeted athlete.

STA is the most distal branch of the external carotid artery. It is vulnerable to trauma because of its superficial nature along the temple and proximity to the underlying bony structures. Trauma to this vessel can cause it to partially sever or contuse, leading to a pseudoaneurysm or arteriovenous fistula.

Common symptoms of STAP include a solitary, painless mass, pulsations, headache, and often ear discomfort that occurs 2 to 6 wk after injury. Less frequent symptoms include visual disturbances, dizziness, pain, or hemorrhage (9). The diagnosis of STAP is initially made with a complete history and physical examination along with confirmatory imaging including color Doppler US, CTA, magnetic resonance angiography, or digital subtraction angiography (6). The most accurate, noninvasive modality to aid in diagnosis is duplex US (9), a dynamic point-of-care study that can be performed in an office setting. CTA evaluates the patency and position of the main trunk and distal branches of the STA, including the transverse facial, frontal, and parietal branches. Limitations of CTA include cost, radiation exposure, and the relative invasive nature of CTA compared to US.

Treatment of STAP is considered when there is 1) a risk of spontaneous rupture, particularly in patients with continued risk of blunt trauma in this exposed area, 2) pain and tenderness, or 3) cosmetic deformity (9). Our patient displayed all these criteria. In most STAP, surgical resection is preferred, given that symptoms are mainly associated with the mass effect and local irritation caused by the aneurysm, and sacrifice of the temporal artery is associated with low morbidity. The procedure of choice is proximal and distal vessel ligation with aneurysm excision, performed utilizing local anesthesia and conscious sedation (3). Potential risks of surgery include infection, hemorrhage, injury to local anatomical structures, aneurysm recurrence, and atrophy/necrosis of the overlying scalp. Alternative treatments include simple methods such as prolonged local pressure (2) or angiography with embolization (7,10). After the lesion heals, patient education regarding the importance of utilizing protective headgear is paramount. After counseling, the athlete may return to full-contact activities without limitations.

Regarding notable sport-related STAP, Campbell et al. (1) presented the first-documented athletic injuries in two separate unhelmeted ice hockey players struck by a puck in the side of the head resulting in a STAP or “puck aneurysm.” Golden et al. (4) described two athletes who developed pseudoaneurysm after being struck in the frontal region of the scalp by a squash ball. Lastly, Romero et al. (9) documented a minor league baseball player who was struck in the head with a baseball as he was sliding into second base. Other sport-related cases include head-to-head collision in rugby, paintball- and softball-inflicted trauma, and contact with an opposing player’s elbow in basketball (9). None of the case reports involving baseball, softball, or ice hockey documented athletes wearing a helmet upon sustaining their injury, illustrating the importance of proper helmet use/fit and the potential importance of chinstrap use for baseball and softball to reduce risk of helmet loss and consequent head injury.

The authors declare no conflicts of interest and do not have any financial disclosures.

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References

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