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Pseudoaneurysms of the superficial temporal artery (STA) are rare lesions. Reported cases typically occur after blunt trauma or penetrating injuries to the scalp along the course of the STA. However, such a complication after cranial surgery has not previously been reported.
A 52 year old man initially presented with Hunt and Hess grade 2 subarachnoid haemorrhage. Subsequent cerebral angiography demonstrated a left middle cerebral artery bifurcation aneurysm. The patient underwent a left pterional craniotomy for clipping of the aneurysm. Postoperatively, the patient developed transient dysphasia, which completely resolved over several days. On discharge at 3 weeks, the patient had made a good recovery.
The patient re-presented 3 months later. A lump had developed over the preceding weeks in the preauricular region under the surgical scar. On clinical examination, a 3×3×2 cm pulsatile mass was seen. It was located anterior to the tragus and at the inferior end of the scalp incision. There was no overlying cutaneous erythema. The wound was explored by reopening the inferior limb of the incision.
The STAs proximal and distal to the aneurysm were identified (fig 1) and ligated. The lesion was dissected off the surrounding soft tissue and excised. Histopathological examination confirmed the diagnosis of pseudoaneurysm.
Pseudoaneurysm of the STA is very uncommon and is usually associated with blunt trauma.1–3 These lesions present as a painless pulsating mass and sometimes their size may rapidly increase.1 These lesions may also be associated with headache, ear discomfort or very rarely facial nerve palsy.3 There have also been reports of pseudoaneurysms of the STA after bypass procedures involving STA and intracranial vessels.4,5 These may rupture with consequent subarachnnoid4 or intracerebral hemorrhage.5
Pseudoaneurysm of the STA as a complication of craniotomy has not been reported in the literature to the best of our knowledge. We think that inadvertent damage to a segment of the STA not involving the entire thickness of the vessel wall (possibly by electrocautery) in the process of fashioning the scalp flap, led to the formation of a pseudoaneurysm. The pulsatile nature of the lesion and its location rendered the pre-operative diagnosis and subsequent surgical treatment simple. In retrospect, we recommend that where there is suspicion of injury to the STA this vessel should be ligated or coagulated and then divided.