|Year : 2021 | Volume
| Issue : 1 | Page : 108-110
Posttraumatic true aneurysm of the superficial temporal artery
Apoorva Vempati1, Sandeep Mahapatra1, Pramod Kumar Pamu2
1 Department of Vascular Surgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
2 Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Submission||29-Apr-2020|
|Date of Acceptance||05-May-2020|
|Date of Web Publication||20-Feb-2021|
Department of Vascular Surgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Most superficial temporal artery (STA) aneurysms are pseudoaneurysms that occur following a trivial trauma to the temporal region. True aneurysms of the STA are very rare. They occur usually due to congenital defects in vessel wall or atherosclerotic degeneration. We report a case of true aneurysm of the STA following trauma which is exceedingly rare. A 23-year-old male presented with painless swelling in front of the right ear for 4 months with a history of trauma to the right temporal region. Examination revealed a painless pulsatile mass of 4 cm × 3 cm size, and the diagnosis was supported by Doppler ultrasound and magnetic resonance imaging. Surgical excision was done. Histological examination showed all the three layers of the arterial wall to be intact, confirming a diagnosis of true aneurysm of the STA.
Keywords: Pseudoaneurysm, superficial temporal artery, true aneurysm
|How to cite this article:|
Vempati A, Mahapatra S, Pamu PK. Posttraumatic true aneurysm of the superficial temporal artery. Indian J Vasc Endovasc Surg 2021;8:108-10
| Introduction|| |
The aneurysms of the superficial temporal artery (STA) account for <1% of the reported aneurysms. Most of these are pseudoaneurysms which develop after blunt or penetrating trauma to the temporal region. True aneurysms of the STA are very rare and usually of congenital, atherosclerotic, or hemodynamic origin. We report a case of true aneurysm of the STA that appeared after trivial head trauma.
| Case Report|| |
A 23-year-old male presented with complaints of swelling in front of the right ear for 4 months. He noticed a small swelling after sustaining injury to the right temple due to hit by the car door. The swelling gradually increased to attain the present size. Local examination showed a painless, pulsatile, vertically oval swelling of size 4 cm × 3 cm in the right preauricular region [Figure 1]. The skin over the swelling was normal. There was no evidence of swellings anywhere else.
Ultrasound examination revealed a well-defined anechoic lesion measuring 35 mm × 26 mm subcutaneously in the right preauricular region showing areas of heterogeneously hypoechoic areas. On color Doppler, the lesion showed turbulent forward and backward flow communicating with the right STA suggestive of a pseudoaneurysm. Magnetic resonance imaging of the brain and face showed evidence of hypointense lesion on T1-weighted and heterogeneously hyperintense lesion in T2-weighted images measuring 35 mm × 26 mm in the subcutaneous planes of right preauricular region – likely a pseudoaneurysm of the right STA. Under local anesthesia, a longitudinal incision was placed over the swelling. On exploration, an intact oval swelling of 4 cm × 3 cm was found, arising from the STA, raising a suspicion of true aneurysm [Figure 2]. The aneurysmal swelling was excised, ligating the inflow and outflow to the sac. The aneurysm was dissected along its posterior aspect to avoid injuries to the facial nerve branches. The aneurysmal sac contained intraluminal thrombus with intact endothelium [Figure 3] as opposed to preoperative imaging suggestive of the diagnosis of pseudoaneurysm. Postoperative recovery was uneventful. Histology revealed all the three layers of arterial wall to be intact, defining the lesion as true aneurysm of the STA [Figure 4] and [Figure 5].
|Figure 2: Intraoperative photograph showing superficial temporal artery aneurysm|
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|Figure 3: Specimen of superficial temporal artery aneurysm (cut section)|
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|Figure 4: Microscopic analysis with Masson Trichrome stain (×40) revealing all the three layers of vessel wall with intraluminal thrombus: Subintimal layer, media, and adventitia|
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|Figure 5: Microscopic examination with hematoxylin and eosin stain (×10) showing focal areas of dystrophic calcification due to degeneration of media as a result of trauma (basophilic strip in the media)|
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| Discussion|| |
A true aneurysm is a localized or diffuse dilatation of an artery that involves intima, media, and adventitia. A false aneurysm, or pseudoaneurysm, always implies a break in the arterial wall with subsequent hematoma formation and eventual hematoma organization to become a connective tissue sac.
Although approximately 400 patients with STA aneurysm were reported in literature up to now, the majority of the cases are posttraumatic pseudoaneurysms.
True aneurysms are seen only in 10% of all STA aneurysms. The exact pathophysiology of the true aneurysms has not been established. However, atherosclerosis and congenital defects in the arterial wall are accused in the etiology. In particular, it has been suggested that the congenital changes in the elastic membrane may cause the development of a true aneurysm. The higher incidence of true aneurysms in elder ages than pseudoaneurysms suggests that the cause can be hemodynamic stress, as well as atherosclerosis.
True aneurysm can also occur when trauma weakens the arterial wall without a break in the wall as with our case.
Commonly,patients with STA aneurysm present with a pulsatile painful or painless mass at some point along the artery.They can also present with throbbing headache,ear discomfort,dizziness,bleeding or rarely with facial nerve paralysis., Our patient did not complain of pain since the event of trauma.
Differential diagnosis includes lipoma, hematoma, lymphadenopathy, supraorbital nerve neuroma, dural arteriovenous fistula, arteritis, cysts, neoplastic disease such as facial nerve schwannoma, parotid gland tumor, meningocele, pericranial sinus, and subcutaneous abscess. Occasionally, STA aneurysm resembles a parotid mass involving the facial nerve that may require superficial parotidectomy.
Diagnosis is confirmed by history, physical examination, Doppler study, and imaging such as ultrasonography. Studies such as computed tomography angiography and magnetic resonance angiography may be used to identify the lesion and to investigate other intracranial lesions. Needle aspiration or core biopsy of the artery must be avoided.
The natural history of true aneurysms of the STA is unknown, while the false aneurysms have been described to enlarge, thrombose, or rupture, if left untreated.
The therapeutic options include conservative surveillance, endovascular embolization, and surgical excision. Nonoperative methods have included observation and application of continuous pressure over the aneurysm, with eventual thrombosis.
Operative intervention is indicated for relief of symptoms, for correction of cosmesis, and to prevent rupture, although precise size criteria for surgery are not established., In our case, surgery was done for cosmetic reasons with concerns of the young boy for increase in the size of the swelling. Resection involves careful dissection with prompt control of the proximal and distal vessels, safeguarding the accompanying veins. Due to the rich facial vascular supply, it is unnecessary to reconstruct vessels.
Super-selective catheter embolization with glue or thrombin injection has been used where the depth of the artery or its contiguity to the facial nerve and the parotid gland complicates surgery; however, there is the risk of embolism and cosmetically nonappealing due to the remnant thrombosed aneurysm.,
Till date, only 34 cases of true aneurysms of STA have been reported in literature. It is speculated that the real incidence of true STA aneurysms has been underreported because of failure to report STA aneurysms.
Pathologic examination is the only way to find out the real incidence of pseudoaneurysm and true aneurysm caused by trauma.
| Conclusion|| |
True aneurysm of STA, though very rare, is a possibility after trauma to the temporal region.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]