2026 年 13 巻 p. 37-38
Letter to the editor: Comment on "Coil embolization of a ruptured traumatic pseudoaneurysm of the middle meningeal artery: a case report".1)
I have read with interest the case report by Nishizawa et al.1) entitled "Coil embolization of a ruptured traumatic pseudoaneurysm of the middle meningeal artery: a case report." They described the endovascular treatment and discussed the management of this pseudoaneurysm. I also experienced and published a similar case.2)
Nishizawa et al.1) suggested that surgery can be challenging due to the friable nature of the aneurysm, which often lacks a satisfactory aneurysmal neck for clip placement. Furthermore, they reported that the risk of intraoperative rupture and other surgical complications is higher with pseudoaneurysm surgery than with surgery for common saccular aneurysms.
However, despite these challenges, operators can overcome obstacles and succeed in managing a middle meningeal artery (MMA) pseudoaneurysm. To treat a space-occupying intracerebral hemorrhage due to an MMA pseudoaneurysm, researchers recommend that neurosurgeons perform decompressive surgery, including excision or coagulation of the MMA pseudoaneurysm.
However, some pitfalls exist in this operation. First, an appropriate craniotomy covering the temporal fossa should be performed, particularly one that includes the proximal segment of the MMA pseudoaneurysm. Wang et al.3) performed a second craniotomy for the removal of an MMA pseudoaneurysm after failing to identify the bleeding focus in the first operation. Appropriate craniotomy for treating an MMA pseudoaneurysm can be planned using preoperative computed tomography angiography. Second, intraoperative rupture of an MMA pseudoaneurysm frequently occurs during bone flap removal, hematoma removal, or dural opening.4) This intraoperative bleeding can be controlled easily with simple coagulation or excision of the MMA pseudoaneurysm. Successful neck clipping of this pseudoaneurysm is highly challenging and impossible in every case.
The MMA enters the intracranial cavity via the foramen spinosum. The MMA bifurcates, at the pterional region, into anterior and posterior divisions. Before bifurcation, the MMA gives off petrosal and cavernous branches. These 2 branches supply the dura mater of the temporal fossa. The petrosal branch courses along the petrous apex and supplies the dura mater of this region and the superior part of the tympanic cavity via the superior tympanic artery. The petrosal branch also supplies the trigeminal ganglion and its nerves. The superior tympanic artery, from the petrosal branch, supplies the greater superficial petrosal nerve and the geniculate ganglion.5) If a pseudoaneurysm of the MMA is located in the petrosal branch, coagulation or excision of the pseudoaneurysm might result in facial or trigeminal nerve palsy. However, most cases of MMA pseudoaneurysm are located in the anterior or posterior branch of the MMA. Sometimes, this pseudoaneurysm is located in a segment of the MMA between the branching point of the petrosal branch and the bifurcation point of the 2 divisions. In this situation, operative treatment for an MMA pseudoaneurysm is safe. I recommend presenting an angiogram of the right external carotid artery with detailed information between the petrosal branch and pseudoaneurysm in Nishizawa et al.'s case.
Whether endovascular treatment for an MMA pseudoaneurysm should be the first treatment of choice is unclear. However, when the MMA originates from the ophthalmic artery, embolization of the MMA is contraindicated. Otherwise, blindness due to embolization of the central retinal artery may occur.6)
What is another contraindication for embolization of the MMA?
No funding resource.
All authors have no conflict of interest.
No.
