Early CTA Head Imaging Identifies Rare Posterior Meningeal Artery Pseudoaneurysm

Although not supported by the literature, early computed tomography angiography (CTA) head imaging allowed for the identification and management of an extremely rare traumatic posterior meningeal artery pseudoaneurysm. Clinicians from Kendall Regional Medical Center in Miami, Florida, wrote about the patient in a case report published in the International Journal of Surgery Case Reports.

“Overall, severe traumatic brain injury (TBI) is incredibly nuanced, and treatment strategies should be tailored for each individual patient,” the authors wrote. “In certain patients with severe TBI and skull fractures, there may be a role for developing protocols to include computed tomography (CT) head angiography in order to not miss meningeal arterial injuries.”

The 69-year-old man was brought to the trauma center after falling 6 feet onto a concrete warehouse floor. On arrival, he had a Glasgow Coma Score of 3 and obvious blunt head trauma.

After a noncontrast CT scan of the brain revealed subarachnoid hemorrhage with diffuse cerebral edema and a basilar skull fracture, the man underwent emergency ventriculostomy, according to the report. CTA head imaging immediately afterward showed a hyperintense posterior cranial fossa lesion. Cerebral angiography followed, leading to the identification of a traumatic PMA pseudoaneurysm, which was then successfully embolized.

Critical care management over the next month included hyperosmolar therapy, tranexamic acid, and early tracheostomy, the authors explained. The patient made slow progress and, on hospital day 30, was transferred to a neurologic long-term acute care hospital.

At follow-up 3 months later, the man was talking with family, eating, drinking, and aggressively working with physical therapy.

“Early identification of meningeal vascular injuries, coupled with aggressive multidisciplinary management, can be lifesaving,” the authors wrote, “and its value cannot be overstated.”

Reference:
Ehrhardt JD Jr, Elkbuli A, McKenney M, Renda M. Multidisciplinary management of a traumatic posterior meningeal artery pseudoaneurysm: A case report and review of the literature. Int J Surg Case Rep. 2021;82:105933. doi:10.1016/j.ijscr.2021.105933