Life Threatening Rupture of A Superficial
Temporal Artery Aneurysm Presenting with Scalp Hematoma - A Rare Presentation
Sunil Munakomi* and Pramod Chaudhary
Department of Neurosurgery, College of Medical Sciences, Nepal
Submission: January 27,2017; Published: May 24, 2017
*Corresponding author: Sunil Munakomi, Department of Neurosurgery, College of Medical Sciences, Nepal, Email: firstname.lastname@example.org
How to cite this article: Sunil M, Pramod C. Life Threatening Rupture of A Superficial Temporal Artery Aneurysm Presenting with Scalp Hematoma - A
Rare Presentation. JOJ Case Stud. 2017; 2(5) : 555596. DOI:10.19080/JOJCS.2017.02.555596.
Herein we report a rare case in a sixty year old lady who presented in hypotensive state with scalp hematoma following rupture of a traumatic aneurysm in a frontal branch of superficial temporal artery. After resuscitation she was undertaken for invasive angiography that revealed the aneurysm. The wound was excised and wound primarily closed. The lady made an uneventful recovery.
Traumatic aneurysm of superficial temporal artery (STA) is a known entity . However, its presentation as life threatening scalp hematoma following its rupture is a rare epiphenomenon. Herein, we report one such case in a 60 year lady and discuss the management undertaken in the same.
A 65 year old lady was brought to the emergency department in the College of Medical Sciences with a history of sudden onset bleeding and swelling on her scalp following a trivial fall at home (Figure 1). The patient was hypotensive at presentation with initial blood pressure of 60/40mm of mercury. She was timely resuscitated. Initial lab investigation revealed hemoglobin of only 4.5gm%. She was therefore adequately transfused blood. Local examination revealed a scalp swelling in the left frontal region of approximately 6x5cm2 with a black crater on its top. There was no ongoing bleed. There was no bruit audible over the swelling or presence of any abnormal dilated vessels surrounding the lesion. There was however a linear scar in the vicinity of the swelling which the patient related to a fall injury she sustained eight months prior. The patient denied similar swelling elsewhere. The patient did not have significant past medical and surgical illnesses. She was not on any medications on a long term basis. There was no history of spontaneous epistaxis, ecchymosed or gum bleeding.
After the patient was hemo-dynamically stable, we performed invasive angiography that revealed an aneurysm in
the STA territory (Figure 2). No other vascular abnormalities were seen. The patient and her relatives were thoroughly
counseled regarding the disease condition and were advised for
The lesion was excised with clear healthy margins (Figure
3). The wound was closed primarily. Patient made an uneventful
recovery and was discharged on the third post operative day.
Histopathology did not reveal any vascular abnormalities. The
patient has been on regular follow up.
STA aneurysm occurs mostly following blunt trauma due
to the superficiality of its location . Other causes include
penetrating injuries, iatrogenic causes such as skull tractions
and sometimes contact sports [3-5].
The main epicenter for the occurrence of the lesion is at
the origin of the frontal branch of the STA wherein it traverses
from the temporalis to the frontalis muscle but is tethered to the
underlying fascia . Presence of loose tissue in the scalp allows
its growth and propensity for its subsequent rupture.
The time lapse from the trauma to the detection of the lesion
is varying from days to 6 weeks in most of the cases . The
patients usually present with history of slowly progressive
swelling with pulsating headache . Pulsatile nature may be
paradoxically absent if there in spontaneous thrombosis within
the aneurysm . Very few patients may present with cosmetic
issues. Most often audible bruit will be heard over the lesion.
There are several methods mentioned so as to diagnose
the condition . Color Doppler ultrasound may be used in
cases of pulsatile lesions. Computed tomography and magnetic
resonance imaging, though noninvasive, cost factor is the main
limiting issue for their routine use. In difficult cases like ours,
wherein there was a rupture with huge scalp hematoma, invasive
angiography has a place to correctly diagnose the condition.
However, there are risks adherent with it. It may have
additional benefits in endovascular obliteration with uses of
coils, thrombin or N Butyl C Acrylate (NBCA) in few selected
cases . Management of this entity diverse from conservative
management, ultrasound guided temporary proximal occlusion
of the STA trunk, endovascular and finally surgical excision of
the lesion .
Intervention for this condition is justified because of the
cosmetic issue and the risk of hemorrhage. Surgical excision is
the preferred modality with proximal and distal ligation of the
main trunk and excision of the aneurysm.
Our case is unique in many ways. Firstly, it was involving
the frontal branch of the superficial temporal artery. Secondly,
it presented 8 months after the history of trauma sustained to
the head. Thirdly, its presentation as a life threatening bleeding
episode as a scalp hematoma has not been previously reported.
This case report highlights the importance of accounting
the fact that superficial temporal artery aneurysm can present
months later the ictal head injury with life threatening scalp
hematoma following its rupture. The timely intervention of this
entity is therefore justified.