Reply to the Editor: "Coil Embolization of a Ruptured Traumatic Pseudoaneurysm of the Middle Meningeal Artery: A Case Report"
Thank you very much for the valuable feedback. We would like to respond to your comments. Regarding the relationship between the petrosal branch of the middle meningeal artery (MMA) and the pseudoaneurysm, it is indeed important to confirm the petrosal branch, which forms the facial arcade with the stylomastoid branch of the posterior auricular or occipital artery. In the patient in our case report, the pseudoaneurysm extended close to the foramen spinosum, which affected our ability to clearly identify the petrosal branch. It was not clearly depicted on angiography performed immediately after embolization either, which was the last imaging performed. However, it might have been visible had angiography been performed later.
Concerning the contraindications for MMA embolization, as you pointed out, it is necessary to perform embolization with careful attention to dangerous anastomoses, such as those with the ophthalmic artery and facial arcade. In our patient, imaging of the internal carotid artery on the affected side revealed the ophthalmic artery, but no anastomosis with the MMA was observed. In cases of epidural or subdural hematomas accompanied by midline shift or compression of the oculomotor nerve, craniotomy for urgent decompression is imperative, and endovascular therapy with anticoagulant use should be avoided. Although intracerebral hemorrhage had occurred in our patient, there was no midline shift, and external decompression was not necessary; therefore, endovascular treatment was selected. Moreover, in the case reported by Moon et al., the pseudoaneurysm appears to have been located relatively distally on the anterior branch of the MMA. At this location, craniotomy provides relatively easy access and observation, and indeed, the pseudoaneurysm was successfully surgically managed. In our case, the pseudoaneurysm was located just beyond the foramen spinosum on the cranial base side. We were concerned that if we proceeded with surgical management, pseudoaneurysm access and observation would be quite difficult owing to a very deep surgical field and brain swelling. Therefore, we elected to proceed with endovascular treatment. Determining the treatment method for MMA pseudoaneurysms requires consideration of which branch the aneurysm arises from and whether it can be safely accessed, observed, and controlled with an open surgical approach.
Conflicts of Interest Disclosure
All authors have no conflict of interest.
