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A false traumatic aneurysm of the superficial temporal artery: case report and literature review

Xie, Fei MDa,; Jianqiang, Hao MDb; Ting, Wang MDb; Richard, Seidu A. MD, PhDb,c

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International Journal of Surgery: Global Health: September 2020 - Volume 3 - Issue 5 - p e22
doi: 10.1097/GH9.0000000000000022
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Abstract

Pseudoaneurysms or false aneurysms originating from superficial temporal artery (STA) are rare and often seen as facial swellings1,2. The occurrences STA pseudoaneurysms (STAP) have been associated largely with blunt head injury3,4. These forms of aneurysms often involve the intimal and media layers of the arterial wall5,6. STAPs consists about 89% of traumatic STA aneurysms3. These aneurysms occurs during a partial transection of the arterial wall resulting in extravasation of blood5. The extravasated blood slowly ousts adjacent soft tissues resulting in the formation of a fibrous false capsule around the hematoma3,5. Currently, the gold standard radiological modality for evaluating these lesions is computed tomography angiography (CTA)7. The treatment of choice is surgical intervention. Single cases or case series of STAPs have been reported in literature since the first case was reported in 16441,2. So far, ~500 cases have been reported at various locations across the world. We report yet another case of traumatic STAP in accordance to the 2018 SCARE guidelines8.

Case report

We present a 51-year-old man with a 1-year history of a pulsatile mass on the left forehead (Fig. 1A). He suffered a blunt trauma at the temporal region of the left forehead a year prior. At the time of injury, there was no laceration and no loss of consciousness. A pulsatile mass appeared at the left temporal region of the forehead a month after the trauma. Initial, the mass was small but with time, it keeps increasing in size with an ugly cosmetic look. His past medical history was unremarkable. On physical examination, the mass had compressible, nontender, and pulsatile features. There were no cranial nerves deficits. General physical examination was unremarkable. Routine laboratory investigations where at normal rangers. Chest x-ray and ECG were grossly normal.

Figure 1
Figure 1:
A, An animated image of the patient showing a pulsatile mass on left forehead. B, An enhanced computer tomographic scans showing a mass containing blood (red arrow). C, Computed tomography angiography showing a left superficial temporal artery pseudoaneurysm.

An enhanced computed tomographic (CT) scans revealed a mass containing blood (Fig. 1B) while a CTA confirmed left STAP (Fig. 1C). After sedation, local anesthesia was infiltrated around the swelling. Subsequently, the lesion was total resected via surgery (Fig. 2A). The proximal and distal ends of the parent artery were ligated before the resection. We carefully reconstructed the parent artery to allow for continuous blood supple to the areas supplied by the artery. The patient recovered well with an overall good cosmetic look. Histopathologic findings confirmed the diagnosis of pseudoaneurysm (Figs. 2B, C). Two years follow-ups with CT showed no residual lesions or recurrence of the lesion (Fig. 2D).

Figure 2
Figure 2:
A, Is an intraoperative image showing the lesion before it was totally resected. B and C, Histopathologic images showing the typical characteristic of a pseudoaneurysm. D, A postoperative follow-up computed tomography angiography showing no residual lesions or recurrence of the lesion and reconstructed parent artery.

Discussion

The of occurrences STAPs have been associated largely with blunt head injury3–5. It is estimated that 95% STAPs originates from blunt trauma3. Nevertheless, penetrating trauma or iatrogenic causes accounts for the remaining 5% of cases reported in literature3,9. A few pediatric cases have been reported although majority of cases are adults10,11. The mechanisms of blunt trauma comprise of assault, falls as well as sports. Also, iatrogenic sources comprise of surgical removal of basal cell carcinoma, hair transplantation, as well as CT-guided biopsies3,5. The appearance of the facial swelling verifies from 2 days to 17 years after the blunt trauma5. Our patient noticed a pulsatile swelling on his forehead a month after the traumatic event.

Trauma on the STA results in a tear in the innermost layers of the arterial wall leading to extravasation and concealment of blood in the innermost layers and then hematoma formation5,6,12. Subsequently, the formation of a tinny perivascular fibrous capsule around the hematoma occurs resulting in a painless pulsatile swelling3,12,13. The natural history of STAP is often a blunt trauma or surgery at the temporal region followed by pulsatile mass associated with headache13–15. Most patients also present with facial pain, earache as well as facial droop as a result of compression on cranial nerve VII12,16. Our patient did not experience any cranial never deficits. Differential diagnosis of STAP may include, lipoma, sebaceous cyst, abscess, meningocele, lymphadenopathy, neuroma of the supraorbital nerve, angiofibroma, encephalocele as well as lymphoid hyperplasia3,6,12,15,17. Therefore, it is very necessary to report the occurrences of STAP because the swelling could be mistaken for other lesions leading to inappropriate treatment especially in facilities with no modern radiologic modalities.

Radiologically, skull x-ray is very valuable in detecting associated fractures18. Nevertheless, x-ray is unable to determine the content of the swelling. Duplex ultrasound is very useful in detecting the content of the swelling11. However, CT scan and magnetic resonance imaging (MRI) are very advantageous in detecting accompanying arteriovenous malformations as well as fistula of the middle meningeal artery18. The gold standard radiologic modality used in evaluating STAPs is arteriography7,18. We utilized CTA to confirm the diagnosis of the lesion in our case. CTA often aids in confirming the diagnosis as well as ruling out other differential lesions above.

A wide range of treatment options such as thrombin injection, catheter-based embolization as well as surgical resection has used to treat patient with STAPs5. Conservative treatment has also been adopted with no reduction in size of the swelling. Therefore, conservative management option is often not adopted because of constant distress, headaches, possibility of rupture of STAP as well as cosmetic reasons5. Ultrasound-guided compression of the STAP has also been tried with little success5. Ultrasound-guided thrombin injection has been used to successfully treat a patient with STAP19. Nevertheless, diffusion of thrombin into the swelling is often poorly coordinated resulting in seizures as well as infarctions of the scalp20.

Surgical resection of the lesion is the best treatment option for patients with STAP5,18. It is advocated that; the artery should be ligation at both ends of the lesion and subsequently resection of the pseudoaneurysm during surgery5,10. It is further advocated that, the lesion should dissection carefully under general anesthesia to avert postoperative facial nerve palsy18,21. We resected the lesion after infiltration with local anesthesia because the lesion was small and did not exhibit any compressive symptomatology. In huge and distorted STAPs, end to end anastomosis or arterial grafting is often obligatory to restore blood flow to vital structures5. We carefully reconstructed the parent artery to allow for continuous blood supple to the areas supplied by the artery. Furthermore, uninterrupted facial nerve monitoring and recurrent stimulation may be used to decrease the chances of injury to terminal nerve branches as well as avert a facial palsy5,22. Hypoglossal nerve palsy as a result of stretching the nerve during mobilization of the upper segment of the external carotid artery has also been reported as a surgical complication23.

Endovascular therapy is an alternative to surgical resection21. The most preferred endovascular treatment modality is coil embolization. Coil embolization is often an adjunct treatment modality to surgical resection5. Coil embolization has been magnificently used to treat life-threatening bleeding from a ruptured STAP24. Other embolization methods include endovascular obliteration, percutaneous endo-obliteration with coils, glue, or ethylene vinyl alcohol copolymer12,25. Histologically, a cross-section of the STAP often exhibits obvious stretching of the artery26. The typical arterial wall configuration is usually transformed via fibroblast proliferation as well as loose connective tissue in the vicinity of the pseudoaneurysms26. Some authors detected atherosclerosis with intimal thickening as well as calcification in the media but no substantial inflammation10,26.

Conclusions

It is very necessary to report the occurrences of STAP because the swelling could be mistaken for other lesions leading to inappropriate treatment especially in facilities with no modern radiologic modalities. CTA often aids in confirming the diagnosis as well as ruling out other lesions. Surgical resection is still the best treatment option for patients with STAP. All STAPs should be surgically resected because of coatomic reasons.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethics approval

This case was reported or written in according to ethical committee of West China Hospital criteria for reporting or writing case reports. The patient and relatives were informed about our intension to involve him in a case study and they agreed to partake in the study.

Funding source

None.

Authors’ contributions

All authors contributed toward data collection, drafting and critically revision of the paper and agree to be accountable for all aspects of the work.

Conflict of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number

None.

Guarantor

All authors.

References

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Keywords:

Angiography; False aneurysm; Traumatic; Pulsatile mass; Pseudoaneurysm

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.