Traumatic aneurysm of the middle meningeal artery presenting with traumatic middle meningeal arteriovenous fistula: case report

Abstract

Objective: Traumatic arteriovenous fistula (AVF) concomitant with pesudoaneurysm involving the middle meningeal artery is uncommon. Traumatic AVF is also known to occasionally show spontaneous closure. We report a rare case of traumatic pseudoaneurysm of the middle meningeal artery identified after spontaneous closure of a traumatic AVF.
Case presentation: A 36-year-old right-handed man suffered a head injury after falling from a step at home, and was brought to our institute. The patient showed no neurological deficits. Computed tomography (CT) showed no intracranial hemorrhage and he was discharged to home. Six days later, he consulted our outpatient clinic because of dizziness and pulsatile tinnitus on the right side. Fracture in the right temporal bone was found on review of the initial CT. Magnetic resonance (MR) imaging showed cerebral contusion in the left temporal lobe and MR angiography demonstrated AVF involving the middle meningeal artery. Angiography revealed direct AVF supplied by the dilated right middle meningeal artery and draining into the cavernous sinus with no cortical venous reflux. Transarterial embolization was attempted 56 days after head injury. Right external carotid artery angiography revealed spontaneous obstruction of the AVF. Selective middle meningeal artery angiography disclosed a small aneurysm, which was embolized completely by coils and glue material.
Conclusion: It may be sometimes difficult to detect a traumatic pseudoaneurysm associated with a traumatic arteriovenous fistula of the middle meningeal artery. Close radiographical follow-up is necessary in this lesion.