History, clinical examination and duplex-sonography revealed a traumatic pseudoaneurysm of the STA in four cases, and a subcutaneous AV malformation of the STA in one case. In all 5 cases surgical resection with ligation of the proximal and the distal vessels of the pseudoaneurysms and AV malformation was performed (Table 1).
Case |
Sex |
Age (years) |
Origin |
Treatment |
APE |
Time to pseudoaneurysm after trauma |
Case 1 |
Male |
45 |
Traumatic |
Surgical resection |
Pseudoaneurysm (Ø: 0.43 cm) |
4 weeks |
Case 2 |
Male |
18 |
Traumatic |
Surgical resection |
Pseudoaneurysm (Ø: 1.10 cm) |
6 weeks |
Case 3 |
Male |
48 |
Atraumatic |
Surgical resection |
AV malformation (Ø: 2.26 cm) |
- |
Case 4 |
Female |
64 |
Traumatic |
Surgical resection |
Pseudoaneurysm |
1 year |
(Ø: 0.92 cm) |
Case 5 |
Male |
24 |
Traumatic |
Surgical resection |
Pseudoaneurysm (Ø: 0.80 cm) |
2 weeks |
Table 1: Case report summary.
APE: Anatomo Pathological Examination, Ø: diameter
Case 1
A 45-year-old male patient presented with pain at the left temporal region. The patient had no pertinant medical history. Four weeks before he was involved in a road accident. He suffered a fracture of the left orbita and a fracture of the right fifth rib. The fracture of the left orbita was treated conservatively. Clinical examination showed a sensitive temporal region and a small pain full pulsatile tumor was observed (Figure 3A). Duplex-sonography of the pulsatile tumor was performed, which confirmed the diagnosis of a pseudoaneurysm of the STA (Figure 3B). The pseudoaneurysm had an average diameter of 0.43 cm, compared to the expected diameter of the STA of approximately 0.10 cm.
Figure 3: Pulsatile tumor at the left temporal region. B: Duplex-sonography of the STA pseudoaneurysm with a diameter of 0.43 cm.
The left temporal region was anesthetized with lidocaine (Xylocaine) 2%. Through a pre-auricular longitudinal incision the pseudoaneurysm was subsequently dissected and visualized. Next, the proximal and distal temporal artery was ligated after which the pseudoaneurysm was completely resected.
The diagnosis of a posttraumatic pseudoaneurysm was histo pathologically confirmed. An arterial vessel with an aneurysmatic dilatation and a prominent intima was seen microscopically. In addition, regional fibrosis was observed already showing signs of organization. Within this fibrous plaque inflammatory cells, including mononuclear and eosinophilic cells, were found. Both the tunica elastica and media were fragmented. No smooth muscle fibers were found in the pseudoaneurysm. Histo-pathologically there were no arguments for arthritis.
The patient recovered uneventfully [8].
Case 2
An 18-year-old male patient presented with a painful progressive swelling at the right temporal region after a motorcycle accident 6 weeks before. During the accident, he fell on the right temporal region while wearing a helmet which initially only caused a small hematoma and headache. As the hematoma resolved, the headache and swelling at the right temporal region progressively increased. Clinical examination showed a sensitive and painful pulsatile swelling at the right temporal region with a maximal diameter of about 1 cm.
Complete resection of the pulsatile protuberance with ligation of the proximal and distal STA was performed under local anesthesia.
The diagnosis of a post traumatically pseudoaneurysm of 1.10 cm was histo pathologically confirmed.
Case 3
A 48-year-old male patient presented with a pulsatile tumor at the left frontoparietal region which caused headache, especially during warm weather. The patient had no pertinent medical history. Clinical examination showed a pulsatile tumor at the left frontoparietal region. By compression of the left STA the pulsatile quality of the tumor disappeared. By compression of the right STA the pulsations remained present.
Duplex-sonography showed a very high systolic and diastolic flow of the left STA compared to the right STA. Angio-MRI confirmed a subcutaneous Ateriovenous (AV) malformation at the left frontoparietal region with a maximal diameter of 2.26 cm. The AV malformation showed a slightly hypertrophic and tortuous parietal branch of the left STA (Figure 4). There was no connection with the intracranial circulation.
Figure 4A: AV malformation on Angio-MRI (coronal plane). B: AV malformation on Angio-MRI (coronal plane) with a slightly hypertrophic and tortuous left STA (red arrow). C: AV malformation on Angio-MRI (sagittal plane). D: AV malformation on Angio-MRI (sagittal plane) with a slightly hypertrophic and tortuous left STA (red arrow).
The afferent left STA proximal to the AV malformation was ligated under general anesthesia. Subsequently the AV malformation was completely resected. The diagnosis of an AV malformation was confirmed histo pathologically. Recovery was uneven full.
Case 4
A 64-year-old female patient presented with a painful progressive swelling at the left temporal region. One year before the patient had fallen on her head and the head wound was sutured by the general practitioner. Clinical examination showed a painful pulsatile swelling at the left temporal region under the year-old scar of the head wound. The scar was re-incised under general anesthesia. The pseudoaneurysm was visualised and the proximal and distal STA ligated. Finally, the pseudoaneurysm was completely resected.
Case 5
A 24-year-old male patient presented with a pulsatile tumor at the right anterior temporal region 2 weeks after a traumatic head to head injury during a football match. Initially a large hematoma was present which gradually resolved except for a small swelling. Clinical examination showed a painful pulsatile swelling at the right anterior temporal region. By proximal compression the pulsations diminished, in contrast to distal compression wherein the pulsations remained present. Duplex-sonography confirmed the diagnosis of a posttraumatic pseudoaneurysm of the anterior branch of the STA with an average diameter of 0.80 cm. Surgical resection under local anesthesia (lidocaine (Xylocaine) 2%) was performed with ligation of the proximal and distal anterior branch of the STA.
Histopathological diagnosis of a posttraumatic pseudoaneurysm of 0.80 cm was confirmed. The tunica media and lamina elastic interna of the tunica intima suddenly disappeared. In other words, a fragmentation and loss of these inner layers was present, concordant with a pseudoaneurysm. The remaining lumen of the arterial vessel consisted of adventitia filled with thrombus (Figure 5).
Figure 5A: Transverse section of the pseudoaneurysm (4x magnification). B: Transverse section of the pseudoaneurysm (10x magnification). Black arrow: fragmentation and loss of the tunica media and lamina elastic interna of the tunica intima. The lumen of the pseudoaneurysm consisted of adventitia filled with thrombus.