Epidural hematomas occur because of trauma, often to the temple, where the middle meningeal artery is located. Left external injection, demonstrating fistula between left middle meningeal artery and middle meningeal veins. This study evaluated the efficacy of middle meningeal artery mma embolization for organized chronic subdural hematoma ocsdh. The causative vessel is usually the middle meningeal artery, tearing as a consequence of brain trauma. Middle meningeal artery embolization for the management of.
Epidural hematoma is an emergent neurosurgical disease that can be managed with close clinical and radiographic observation or surgical evacuation. How reliable is the middle meningeal artery in the diagnosis. Intracranial epidural hematoma occurs in approximately 2% of patients with head injuries and 515% of patients with fatal head injuries. Traumatic pseudoaneurysms of the middle meningeal artery mma are rare occurrences that are usually associated with an underlying skull fracture. The middle meningeal artery in the middle fossa has anastomotic connections with the ophthalmic system and the meningeal branches of the cavernous carotid artery see fig. Bleeding accumulates in the epidural space, outside the dura which is the lining of the brain.
Trauma to this region damages the artery leading to the commonly recognised form of extradural haematoma. Listing a study does not mean it has been evaluated by the u. The patient might undergo no loss of consciousness, brief loss or a. Thus, only 20 to 30% of epidural hematomas occur outside the region of the temporal bone. The vein emerges from the maxillary vein via the pterygoid plexus, a. Twentyone patients had extravasation of contrast medium from meningeal arteries. It results from damage to cerebral veins as they empty into the dural venous sinuses. Epidural hematoma commonly results from a blow to the side of the head. Traumatic arteriovenous fistulae of the middle meningeal. Pseudoaneurysms of the middle meningeal artery represent fewer than 1% of all intracranial aneurysms. Archives epidural hematoma and middle meningeal artery. The middle meningeal artery is the largest branch of the meningeal arterial network, by far. When they rupture, mma pseudoaneurysms frequently cause epidural hematomas and occasionally ipsilateral subdural or subarachnoid hemorrhage. Among the several treatment methods for recurrent csdh, middle meningeal artery mma embolization has been suggested as a method for treating refractory csdh.
It is usually found in the temporoparietal region where a skull fracture will cross the path of the middle meningeal artery or the dural branches. Multiple connections to other key vessels, including ophthalmic, internal carotid, mht, ilt, ascending pharyngeal, occipital these can be. Vertex epidural hematoma associated with traumatic arteriovenous fistula of the middle meningeal artery. Epidural hematoma occurs as a result of head trauma and subsequent acute hemorrhage, primarily from the middle meningeal artery between the skull and the dura mater. Mma embolization has been employed as the sole therapy figure 1 and as a preoperative or postoperative. Jan 21, 2015 the middle meningeal vein parallels the path of the middle meningeal artery. The natural history of traumatic aneurysms of the middle meningeal artery mma is not well known, but patients with these lesions are more likely to have delayed bleeds. Classically due to injury of the middle meningeal artery, a branch of the maxillary artery from the eca. Because of the firm attachment of the dura to the inner table of the skull, epidural hematomas tend to be smaller and more confined than the subdural hematomas. Epidural haematoma definition of epidural haematoma by. Epidural hematomas are not essentially related to a skull fracture located superiorly. The temporal region is most frequently involved in epidural hematoma 7080% of the cases as the bone is thin and the middle meningeal artery lies close to it. Posterior cranial fossa venous extradural haematoma.
While temporal pole is regarded as a venous epidural hematoma, the presence of fistula argues for a more complicated pathology, with arterialized pressures in the. Epidural hematoma middle meningeal artery rupture youtube. Because of the way the dura is attached to the skull, small. It can also arise in the posterior fossa as a result of blood loss from a venous sinus. An epidural hematoma forms when the head impact is of sufficient force to either pull the meninges away from the inner table of the skull or cause a skull fracture. The middle meningeal artery is classically involved, especially with a skull fracture. Edh can also occur secondary to the rupture of a vein, particularly if the middle meningeal vein or dural sinuses are involved. Epidural hematoma definition of epidural hematoma by. Do not cross suture lines because of the tight adherence of the dura to the calvarium and thus have a biconvex or elliptical appearance.
The cerebral angiogram revealed a middle meningeal artery. Abstract medial convexity of the temporal portion of the middle meningeal artery has been accepted as a reliable angiographic sign of the presence of an epidural haematoma. Middle meningeal artery embolization for refractory chronic subdural hematoma. An injured middle meningeal artery is the most common cause of an epidural hematoma. The impact of coagulopathy on the outcome of traumatic epidural hematoma. Intraparenchymal haematoma related to true middle meningeal. Since the earliest clinical description of an epidural hematoma edh, treatment with prompt surgical evacuation has been. Pdf efficacy of middle meningeal artery embolization for. Middle meningeal artery or vein was identified as a source of bleeding in 50% of the operated cases.
Pseudoaneurysms of the middle meningeal artery mma account for fewer than 1% of all intracranial aneurysms, but in literature, in all patients with cranial fractures that cross over the mma and its branches, several vascular lesions are found during angiography. Middle meningeal artery embolization in recurrent chronic. Rarely angiography can demonstrate middle meningeal artery laceration and contrast extravasation from middle meningeal artery into paired middle meningeal veins known as tram track sign. Epidural hematoma knowledge for medical students and. Nov 02, 2015 among the several treatment methods for recurrent csdh, middle meningeal artery mma embolization has been suggested as a method for treating refractory csdh. Almost always arterial explaining the progressive growth of the hematoma. A chronic epidural hematoma cedh caused by posttraumatic pseudoaneurysm of the middle meningeal artery mma has not yet been reported. Apr, 2016 epidural hematoma is an emergent neurosurgical disease that can be managed with close clinical and radiographic observation or surgical evacuation. The middle meningeal vein parallels the path of the middle meningeal artery.
Endovascular embolization of the middle meningeal artery was performed in two cases of refractory chronic subdural haematoma csdh after repeated burr hole and irrigation surgeries. Extradural hematoma vs subdural hematoma radiology. Prognosis, even with a relatively large hematoma, is in general quite good, as long as the clot is evacuated promptly. Because of the way the dura is attached to the skull, small hematomas can cause significant pressure and brain injury. Extradural haematoma are classically considered to arise from a blow to the thin temporal bones of the cranium. Almost always venous due to tearing of subdural cortical bridging veins which extend to the dural sinuses. Most cases involve skull fractures over the lateral convexities of the hemispheres, with rupture of middle meningeal artery branches. This study aimed at describing the variant anatomy of intracranial part of middle meningeal artery in a black kenyan population. It shows population variations, but reports from african populations are scanty. Subdural venous blood collects between the dura and the arachnoid mater. The goal of middle meningeal artery mma embolization is to devascularize the subdural membranes to a sufficient extent such that the balance is shifted from the continued leakage and accumulation of blood products towards reabsorption. The middle meningeal artery may contribute to the supply of the second and third trigeminal divisions in addition to the facial nerve. Surgical management of acute epidural hematomas request pdf. The embolization prevented expansion of the csdh in both cases, and the haematoma disappeared completely in one case.
Chronic epidural hematoma caused by traumatic intracranial. Apr, 2016 fishpool sj, suren n, roncaroli f, ellis h. May 01, 2001 read vertex epidural hematoma associated with traumatic arteriovenous fistula of the middle meningeal artery. Underlying these bones lie the middle meningeal artery closely applied to the meningeal layer of dura mater. Jan 21, 2015 rupture of the middle meningeal artery can cause epidural hematoma, an accumulation of blood between the dura mater and the skull. Read vertex epidural hematoma associated with traumatic arteriovenous fistula of the middle meningeal artery.
Subdural bleeding is usually venous in nature, rather than arterial. Epidural hematoma epidural hematoma clinical presentation. Frontal and occipita l epidural hematomas each constitute about 10%, with the latter occasionally extending above and below the tentorium. Epidural hemorrhages edh usually occur in the middle fossa via laceration of the middle meningeal artery. The vascular structures mentioned above, especially the middle meningeal artery, can be compromised in this setting, leading to bleeding and hematoma formation. Nontraumatic middle meningeal artery aneurysm and rupture resulting in intracranial haemorrhage is rare. Embolization of the middle meningeal artery for refractory. Oct 10, 2017 efficacy of middle meningeal artery embolization in the treatment of refractory chronic subdural hematoma. Typical symptoms are due to compression of the brain and appear after a lucid interval that follows an initial loss of consciousness. Middle meningeal artery embolization for treatment of chronic. Determining when surgery is not appropriate is just as critical as establishing when to operate for certain neurologic diseases. Vertex epidural hematoma associated with traumatic. Expanding highvolume epidur al hematomas can produce a midline shift and.
Skull fracture from blunt trauma causes laceration of arterial vessels, most commonly the middle meningeal artery. The location of the epidural is near the site of fistula. Thus, we report treating a patient who suffered from both ac and recurrent csdh with burrhole. Rarely angiography can demonstrate middle meningeal artery laceration and contrast extravasation from the middle meningeal artery into paired middle meningeal veins known as tram track sign. Mciver ji, scheithauer bw, rydberg ch, atkinson jl. The vein emerges from the maxillary vein via the pterygoid plexus, a collection of veins near the cheek. Emergency treatment requires decompression of the haematoma, usually by craniotomy. Middle meningeal artery embolization for chronic subdural. In contrast to subdural hematomas, a tremendous force is usually required. This is a type of bleeding on the brain has a distinctive period. Av fistulae of the mma may prevent formation of epidural haematoma, but they are frequently associated with so. The state of being unconscious in edh depends on the force of impact. Rupture of the middle meningeal artery can cause epidural hematoma, an accumulation of blood between the dura mater and the skull. Traumatic epidural vs subdural hematoma school of medicine.
Traumatic pseudoaneurysms of the middle meningeal artery mma are rare, associated with skull fractures, and have a high mortality rate. In this paper, we described a series of patients with epidural hematoma who underwent angiotomography cta for mma vascular lesion diagnosis. Middle meningeal artery an overview sciencedirect topics. The cerebral angiogram revealed a middle meningeal. A medical emergency found in 5 to 15% of fatal head injuries, in which blood accumulates in the epidural space due to blood leaking from a torn or disrupted middle meningeal artery, resulting in compression of the braindura mater. Ruptured pseudoaneurysm of the middle meningeal artery. The middle meningeal artery is involved in 75% of edh as it lies underneath the pterion, which leads to a high risk of arterial rupture. Fracture occurs most commonly in the region of the temporal bone. Middle meningeal artery embolization for treatment of chronic subdural hematoma the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. The patient might undergo no loss of consciousness, brief loss or a prolonged one. Differential diagnosis with large haematomas, there is rarely significant confusion as to the correct diagnosis. Epidural hematomas occur when an artery is injured and arterial blood accumulates between the dura and the calvarium. Middle meningeal artery embolization the goal of middle meningeal artery mma embolization is to devascularize the subdural membranes to a sufficient extent such that the balance is shifted from the continued leakage and accumulation of blood products towards reabsorption.
In the present case, a 73yearold man was admitted to hospital with a history of a minor head trauma. Usual origin from the proximal internal maxillary artery imax, with multiple clinicallyimportant variants. Clinical importance of the middle meningeal artery. Computed tomography angiography for detection of middle. Many diseases, including dural arteriovenous fistula davf, pseudoaneurysm, true aneurysm, traumatic arteriovenous fistula avf, moyamoya disease mmd, recurrent chronic subdural hematoma csdh, migraine and meningioma, can involve the mma.
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