Delayed Spontaneous Resolution of a Traumatic Middle Meningeal Artery Pseudoaneurysm.

BACKGROUND Middle meningeal artery (MMA) aneurysms are a very rare entity, comprising less than 1% of all intracranial aneurysms. In particular, traumatic MMA pseudoaneurysms (MMAP) are reported in the literature to have a poor outcome in about 20% of cases. Moreover, in extremely rare cases, MMAPs can spontaneously thrombose. CASE REPORT We present the case of a 42-year-old Hispanic man with multiple craniofacial hemangiomas and history of chronic migraines that increased in frequency after blunt head trauma 1 month prior to initial evaluation. CTA and brain MRI showed a right-sided MMAP adjacent to the foramen spinosum with a pan-hemispheric subdural hematoma and no associated skull fractures. The MMAP was not visualized 2 days later on digital subtraction angiography (DSA) and was therefore presumed to be thrombosed. CTA at 3 months showed interval progression of the MMAP with subsequent spontaneous resolution on CTA at 10 months. CONCLUSIONS Knowledge regarding MMAPs is limited since it is based on a small number of cases and literature reviews. Additional studies are needed to elucidate the true incidence and natural course of this entity and produce adequate treatment guidelines.

Clinical implications in orbital and pterional flap surgeries as well as radioimaging studies to determine topographical prevalence and characterization of meningo-orbital foramen in orbits of the Indian population / Implicaciones clínicas en cirugías de colgajo orbitario y pterional, así como estudios de radioimagen para determinar la prevalencia topográfica y la caracterización del foramen meningoorbitario en órbitas de la población india

SUMMARY: The pear-shaped bony orbit connects with intracranial cavity via foramina's and fissures. The Meningo-orbital Foramen (MOF) is usually present in greater wing of sphenoid close to lateral edge of Superior orbital fissure. It provides a route for an anastomosis between the orbital branch of the middle meningeal artery (MMA) and recurrent meningeal branch of Ophthalmic Artery (OA) and hence, risk of damage during surgeries can occur. To verify occurrence and location, with morphology of MOF in dry orbits and the impending clinical hazards in surgeries pertaining to the orbit, document and analysis it to determine a standardized guideline. The presence for MOF was studied in 446 dry orbits with its location from the supra orbital margin (SOM), front zygomatic suture (FZS), the lateral tubercle of Whitnall (WT)and the lateral end of superior orbital fissure (SOF) along with its patency, laterality and number of foramina's present. Nylon probes, long divider/pins, compass and Vernier callipers was used to check the patency and various parameters. The study noted the percentage prevalence of MOF as 69 % with communication with middle cranial fossa (MCF) being 76 % of 69 % and the average distance from SOM, FZS, WT and lateral end of SOF being 35.58 mm, 24.9 mm, 26.6 mm and 0.92 mm. On comparison with various population studies, certain similarities and differences with regards to different parameters were noted. Prevalence of MOF was mostly unilateral and showed multiple foramina, that can act as channels for arteries, a variant of MMA or OA, that supply orbital structures or tumour growths. Thus, awareness of this variation is of prime importance to ophthalmologists and neurosurgeons as well as interventional radiologists, in preventing haemorrhagic condition which could further raise the difficulties in operative procedures and surgical outcomes.

RESUMEN: La órbita ósea en forma de pera se conecta con la cavidad intracraneal a través de forámenes y fisuras. El foramen meningoorbitario (MOF) suele estar presente en el ala mayor del esfenoides cerca del margen lateral de la fisura orbitaria superior. Proporciona una ruta para una anastomosis entre la rama orbitaria de la arteria meníngea media (MMA) y la rama meníngea recurrente de la arteria oftálmica (OA) y, por lo tanto, puede ocurrir riesgo de daño durante las cirugías. Para verificar la ocurrencia y ubicación, con la morfología de MOF en órbitas secas y los peligros clínicos inminentes en cirugías de la órbita, documentarlo y analizarlo para determinar una pauta estandarizada. Se estudió la presencia de MOF en 446 órbitas secas desde el margen supraorbitario (MOS), sutura cigomática frontal (FZS), el tubér- culo lateral de Whitnall (WT) y el extremo lateral de la fisura orbitaria superior (SOF) junto con su permeabilidad, lateralidad y número de forámenes presentes. Se utilizaron sondas de nailon, divisores / pasadores largos, brújula y calibradores Vernier para comprobar la permeabilidad. En el estudio se pudo observar que la prevalencia porcentual de MOF era del 69 %, siendo la comunica- ción con la fosa craneal media (MCF) del 76 % del 69 % y la distancia promedio desde SOM, FZS, WT y el extremo lateral de SOF era de 35,58 mm, 24,9 mm, 26,6 mm y 0,92 mm. En comparación con varios estudios de población, se observaron ciertas similitudes y diferencias con respecto a diferentes parámetros. La prevalencia de MOF fue mayoritariamente unilateral y mostró múltiples forámenes, que pueden actuar como canales para las arterias, una variante de MMA u OA, que irrigan estructuras orbitarias o crecimientos tumorales. Por lo tanto, la conciencia de esta variación es de primordial importancia para los oftalmólogos y neurocirujanos, así como para los radiólogos intervencionistas, en la prevención de una enfermedad hemorrágica que podría aumentar aún más las dificultades en los procedimientos y los resultados quirúrgicos.

Safety of Onyx Transarterial Embolization of Skull Base Dural Arteriovenous Fistulas from Meningeal Branches of the External Carotids also Fed by Meningeal Branches of Internal Carotid or Vertebral Arteries.

PURPOSE: To analyze the angiographic and clinical results of transarterial embolization with Onyx (Medtronic-Covidien, Irvine, CA) in dural arteriovenous fistulas (DAVFs) partially fed by arteries arising from the carotid siphon or the vertebral arteries. METHODS: We isolated 40 DAVFs supplied by either the tentorial artery of the internal carotid artery (ICA) or the posterior meningeal artery of the vertebral artery. These DAVFs were embolized with Onyx through the middle meningeal artery or the occipital artery. We reviewed the occurrence of reflux into the arteries of carotid or vertebral origin. RESULTS: In all the cases, reflux occurred into the first millimeters of the DAVF arterial feeders arising from carotid or vertebral arteries but slowly enough to be controlled by interruption of Onyx injection. Reflux was always minimal and Onyx never reached the ostium of the arteries. No cerebral ischemic complications occurred in our series. CONCLUSION: The behavior of Onyx is clearly different from that of cyanoacrylate glue, resulting in superior control during injection. Reflux into arteries arising from the ICA or vertebral artery during DAVF treatment always carries a risk of unintentional non-target embolization of normal cerebral vasculature but Onyx appears to be safe in this situation.

Skull base fracture involving the foramen spinosum - an indirect sign of middle meningeal artery lesion: case report and literature review.

Skull base fractures comprise a relatively common finding among trauma patients. Before the widespread use of computed tomography (CT), these lesions used to be misdiagnosed. Currently, with improved imaging technology, diagnosis of skull base fractures is no longer cumbersome. On the other hand, cranial fractures involving the foramen spinosum are rarely described in the literature. In this present article, we report on a patient affected by head trauma, who suffered from a vault fracture towards the foramen spinosum and acute epidural hematoma (EH) due to middle meningeal artery injury. We further discuss the clinical consequences of foramen spinosum fracture.

Iatrogenic pseudoaneurysm of the middle meningeal artery after external ventricular drain placement.

External ventricular drain (EVD) placement is often a routine but lifesaving neurosurgical procedure performed throughout the world. Misadventures involving the procedure are well documented throughout the literature. However, we present a unique case of middle meningeal artery pseudoaneurysm formation after EVD placement not before described and provide a review of the literature.

Computed tomography angiography for detection of middle meningeal artery lesions associated with acute epidural hematomas.

BACKGROUND: The natural history of traumatic aneurysms of the middle meningeal artery (MMA) is not well known, but patients with these lesions are more likely to have delayed bleeds. In this paper, we described a series of patients with epidural hematoma who underwent angiotomography (CTA) for MMA vascular lesion diagnosis. METHODS: Eleven patients admitted to our emergency unit with small acute epidural hematoma were prospectively studied. All patients with temporal acute epidural hematomas underwent CTA and cerebral angiogram at our institution for diagnosis of posttraumatic lesions of middle meningeal artery. The findings of angiotomography and digital angiography were reviewed by radiologist and angiographers, respectively, to ensure that the lesions were readily diagnosed without knowing the results of angiotomography and to compare CTA findings with standard angiogram. RESULTS: The causes of head injury were traffic accidents, falls, and aggression. Three of these patients presented traumatic MMA pseudoaneurysm. CT angiography was able to diagnose all of them, with dimensions ranging from 1.5 to 2.8 mm. Conventional angiography confirmed the findings of CT angiography, and the lesions presented with similar dimensions at both methods. CONCLUSIONS: We believe that angiotomography can be a useful technique for diagnosis of vascular lesion associated with small epidural hematoma.

[False aneurysm of the median meningeal artery: the importance of angiographic diagnosis. A case report]. / Falso aneurisma da artéria meníngea média. Importância do diagnóstico angiográfico. Relato de caso.

The purpose of this paper is to report a case of false aneurysm of the middle meningeal artery. The authors emphasize the value of "common" carotid angiography in diagnosis and treatment of this rare lesion.