Delayed temporal intraparenchymal hemorrhage caused by rupture of middle meningeal artery pseudoaneurysm after a temporal rim fracture

Delayed temporal intraparenchymal hemorrhage caused by rupture of middle meningeal artery pseudoaneurysm after a temporal rim fracture | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Delayed temporal intraparenchymal hemorrhage caused by rupture of middle meningeal artery pseudoaneurysm after a temporal rim fracture Chen-Ting Cheng, Cheng-Di Chiu, Wei-Liang Chen, Jeng-Hung Guo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4856100/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Middle meningeal artery (MMA) pseudoaneurysms are mostly caused by traumatic brain injury and can lead to severe morbidity because of epidural or subdural hematoma. We present a rare case of delayed rupture of a right MMA pseudoaneurysm that caused a temporal intraparenchymal hemorrhage (IPH). Delayed rupture of an MMA pseudoaneurysm is rare but has devastating consequences. Digital subtraction angiography in patients with traumatic brain injury with temporal rim fracture and temporal IPH may help diagnose this lesion easily and treat the disease earlier. trauma pseudoaneurysm middle meningeal artery blunt cerebrovascular injury fracture Figures Figure 1 Figure 2 Figure 3 Introduction Intracranial pseudoaneurysms account for less than 1% of all intracranial aneurysms and are mostly caused by traumatic head injuries. Middle meningeal artery (MMA) pseudoaneurysms account for 27% of all traumatic intracranial aneurysms and have a high mortality rate. [4,10] It is hypothesized that temporal base fractures cause all three vessel layer injuries of the MMA. The formation of a pseudoaneurysm begins with a whole layer defect of the vessel wall that is sealed by blood clots and the surrounding connective tissues. [8,10] Rupture of an MMA pseudoaneurysm usually occurs soon after a trauma event and causes epidural hemorrhage or subdural hemorrhage. [8] To early diagnosis, researchers have found two computed tomography image features of MMA pseudoaneurysm, including (1) temporal rim fracture and (2) nearby hemorrhage. [5,9,10] Herein, we present a case in which the images fit both features. An MMA pseudoaneurysm was diagnosed using digital subtraction angiography (DSA) and subsequently treated concomitantly with surgery. Illustrative Case A 57-year-old male without a specific medical history was transferred to our emergency department after a motorcycle-to-motorcycle collision. He was comatose with bilateral pupil dilatation to 4.0 mm without light reactivity. Initial brain CT tomography revealed minimal right temporal subdural hematoma and intraparenchymal hemorrhage (IPH), slight pneumocephalus, and a right temporal rim linear fracture (Fig. 1 ). Emergency surgery of the ICP monitor was performed and revealed 3 mmHg initially. After the surgery, the patient was transferred to the intensive care unit for further treatment. His consciousness gradually improved after two days, and he was successfully extubated on postoperative day 7. However, on the 13th day after the trauma event, during the rehabilitation program, his consciousness suddenly dropped to GCS E1V2M5. The right pupil was dilated to 4.0 mm without a light reflex. A brain CT scan was rearranged and revealed right temporal delayed IPH with uncal herniation and a midline shift of 7 mm to the left. CT with contrast enhancement revealed a round spot lesion within the hematoma (Fig. 2 ). A pseudoaneurysm originating from the rupture of the right MMA was suspected. Cerebral DSA confirmed the diagnosis of a right MMA pseudoaneurysm, measuring 14.53 mm × 12.02 mm (Fig. 3 ). We performed a right question-mark craniotomy. The right MMA pseudoaneurysm shell was excised and sent for pathological examination to confirm the diagnosis. The proximal MMA was then coagulated. A hematoma of approximately 50 mL was removed from the right temporal lobe. The brain was soft after hematoma evacuation, and the final intracranial pressure was 4 mmHg. The patient’s consciousness gradually recovered to E4V4M6 with occasional irrelevant speech and a requirement for long-term daily care. The patient was transferred to the rehabilitation ward in stable condition, and his modified Rankin scale (mRs) score was 3 after two months. Discussion MMA pseudoaneurysms are mostly caused by traumatic head injury and have a high mortality rate (20%).[ 10 ] It is postulated that temporal skull rim fracture can injure the artery and is considered a major risk factor. Additionally, 70–90% of MMA pseudoaneurysms are related to bony fractures crossing the MMA in the temporal region.[ 5 ] A hypodense spot within the hematoma close to the temporal base on the CT scan is a definite indicator of pseudoaneurysm formation but is only observed in a few cases.[ 5 , 7 , 10 , 15 ] Researchers have advocated the routine use of computed tomography angiography (CTA) in patients with two predictors ((1) temporal base fracture and (2) nearby hemorrhage) to detect MMA lesions early.[ 5 , 9 , 10 ] The incidence of MMA pseudoaneurysms may have been underestimated. De Andrade et al.[ 3 ] collected the angiographic characteristics of 24 patients presenting with a small epidural hematoma and bony fracture crossing the MMA trajectory after a traumatic event. The results demonstrated that seven patients (29.1%) developed MMA pseudoaneurysms, and 17 patients (70.1%) presented with active MMA bleeding and contrast extravasation. They performed MMA embolization in every patient, and a follow-up brain CT scan did not reveal any hematoma enlargement. Although most MMA lesions are benign and regress without treatment, delayed or 2nd rupture could lead to severe morbidity. This study illustrates the epidemiology of MMA pseudoaneurysms and successfully prevents further deterioration. The mechanism by which a delayed rupture causes IPH remains unclear. Some studies have postulated that enlargement of the pseudoaneurysm makes the dura mater thinner and thus bleeds into the brain parenchyma.[ 9 ] We searched for delayed MMA pseudoaneurysms leading to IPH in the literature and summarized all nine cases (including ours) (Table 1 ).[ 1 , 6 , 11 – 14 , 16 ] The average age of patients with delayed MMA pseudoaneurysms was 54 years. There appeared to be a predominance of men. The initial presentation on CT was a subdural hematoma. The median duration of delayed hemorrhage was 20 days (range, 7–11 months), and the patient rebled on the 13th day. Most ICH sites are located in the temporal lobe. These patients did not undergo CTA until neurological deterioration occurred. A craniotomy for hematoma evacuation was performed, and the MMAs were coagulated, clipped, or embolized. The reasons for selecting direct surgical treatment were as follows: (1) acute onset of comatose status, (2) right temporal delayed hemorrhage with herniation requiring evacuation, and (3) right pupil dilated to 4.0 mm without a light reflex. Eventually, five patients experienced poor neurological outcomes (mRS > 3). Therefore, Montanari et al. suggested arranging CTA 7–10 days after a traumatic episode in cases with two coexisting predictors to prevent undesirable outcomes.[ 10 ] Table 1 Summary of nine cases of delayed MMA pseudoaneurysm formation. Case Authors & years Age Sex Hemorrhage on first CT Temporal fracture Delayed time ICH site Intervention Outcome 1 Pouyanne et al. 1959[ 11 ] 60 F SDH Yes 30 days Temporal Operation Severe disability 2 Kia-Noury 1961[ 6 ] 32 M SDH Yes 7 days Temporal Operation Recovery 3 Sicat et al. 1975[ 13 ] 62 M SDH Yes 24 days Temporal Operation Death due to pneumonia 4 Roski et al. 1982[ 12 ] 54 M NR Yes 10 days Frontal Embolization then operation Recovery 5 Aoki et al. 1992[ 1 ] 75 M SDH Yes 29 days Temporal Operation Vegetative status 6 Singh et al. 2006[ 14 ] 30 M NR Yes 11 months Frontal Operation Recovery 7 Wu et al. 2014[ 16 ] 49 M SDH Yes 16 days Temporal Operation Recovery 8 Montanari et al 2018[ 10 ] 66 M SDH Yes 15 days Temporal Operation Death due to bedridden 9 Our case 57 M SDH Yes 13 days Temporal Operation Severe disability NR: Not-Recorded Intracranial pseudoaneurysm formation after a traumatic episode has been considered a grade 3 blunt cerebrovascular injury (BCVI) according to the Denver grading scale.[ 2 ] In the expanded Denver screening guideline, the patient should undergo CTA for either symptoms or signs of BCVI presentation. Since skull fracture is almost always related to MMA pseudoaneurysm formation, it can be detected in the early phase of a differential diagnosis is considered. According to the new Denver Health Medical Center BCVI screening guidelines, the initial negative CTA findings require further investigation, except when there is a high suspicion. Hence, due to the underestimated prevalence of MMA pseudoaneurysms, we recommend initial CTA screening and/or follow-up with cerebral DSA after 7–10 days in patients with temporal base fractures and nearby hemorrhages. Conclusions We describe a case of delayed MMA pseudoaneurysm rupture leading to IPH, with an initial presentation of two predictors of MMA pseudoaneurysm formation. Careful reading of the initial CT scan and repeating CTA or cerebral DSA 7–10 days later in patients with skull base fractures and nearby hemorrhages can prevent this critical complication. Declarations Ethical Approval This study is limited to description of the clinical course, outcomes of an individual patient without conducting research or involving interventions beyond standard care. The requirement for approval from the institutional review board is then waived for case reports. Competing interests The authors declare that they have no competing interest Authors' contributions Charlton Chen-Ting, Cheng conceptualized the study and wrote the main manuscript Wei-Liang, Chen provided neuroradiological interpretation Cheng-Di Chiu is the reviewer and supervisor of the manuscript, image, tables and the literatures Correspondence to Jeng-Hung Guo Funding No funding Availability of data and materials Not applicable. References Aoki N, Sakai T, Kaneko M (1992) Traumatic aneurysm of the middle meningeal artery presenting as delayed onset of acute subdural hematoma. Surg Neurol 37:59–62. 10.1016/0090-3019(92)90068-x Burlew CC, Biffl WL, Moore EE, Barnett CC, Johnson JL, Bensard DD (2012) Blunt cerebrovascular injuries: redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg 72:330–335 discussion 336–337, quiz 539. 10.1097/TA.0b013e31823de8a0 de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RL, Puglia P, Frudit M, Teixeira MJ (2008) Intracranial vascular lesions associated with small epidural hematomas. Neurosurgery 62:416–420 discussion 420 – 411. 10.1227/01.neu.0000316008.11388.f2 Gerosa A, Fanti A, Del Sette B, Bianco A, Cossandi C, Crobeddu E, Forgnone S, Fornaro R, Panzarasa G (2019) Posttraumatic Middle Meningeal Artery Pseudoaneurysm: Case Report and Review of the Literature. World Neurosurg 128:225–229. 10.1016/j.wneu.2019.05.030 Jussen D, Wiener E, Vajkoczy P, Horn P (2012) Traumatic middle meningeal artery pseudoaneurysms: diagnosis and endovascular treatment of two cases and review of the literature. Neuroradiology 54:1133–1136. 10.1007/s00234-011-1003-7 Kia-Noury M (1961) [Traumatic intracranial aneurysm of the medial meningeal artery after skull base fracture]. Zentralbl Neurochir 21:351–357 Kumar RJ, Sundaram PK, Gunjkar JD (2011) Traumatic giant pseudoaneurysm of the middle meningeal artery causing intracerebral hematoma. Neurol India 59:921–922. 10.4103/0028-3886.91387 Lim DH, Kim TS, Joo SP, Kim SH (2007) Intracerebral hematoma caused by ruptured traumatic pseudoaneurysm of the middle meningeal artery: a case report. J Korean Neurosurg Soc 42:416–418. 10.3340/jkns.2007.42.5.416 Marvin E, Laws LH, Coppens JR (2016) Ruptured pseudoaneurysm of the middle meningeal artery presenting with a temporal lobe hematoma and a contralateral subdural hematoma. Surg Neurol Int 7:S23–27. 10.4103/2152-7806.173564 Montanari E, Polonara G, Montalti R, Vivarelli M, Ricciuti RA, Giorgetti R, Tagliabracci A (2018) Delayed Intracerebral Hemorrhage After Pseudoaneurysm of Middle Meningeal Artery Rupture: Case Report, Literature Review, and Forensic Issues. World Neurosurg 117:394–410. 10.1016/j.wneu.2018.06.158 Pouyanne H, Leman P, Got M, Gouaze A (1959) [Traumatic arterial aneurysm of the left middle meningeal artery. Rupture one month after the accident. Temporal intracerebral hematoma. Intervention] Neurochirurgie 5:311–315 Roski RA, Owen M, White RJ, Takaoka Y, Bellon EM (1982) Middle meningeal artery trauma. Surg Neurol 17:200–203. 10.1016/0090-3019(82)90280-4 Sicat LC, Brinker RA, Abad RM, Rovit RL (1975) Traumatic pseudoaneurysm and arteriovenous fistula involving the middle meningeal artery. Surg Neurol 3:97–103 Singh M, Ahmad FU, Mahapatra AK (2006) Traumatic middle meningeal artery aneurysm causing intracerebral hematoma: a case report and review of literature. Surg Neurol 66:321–323 discussion 323. 10.1016/j.surneu.2005.11.029 Wang CH, Lee HC, Cho DY (2007) Traumatic pseudoaneurysm of the middle meningeal artery: possible indicators for early diagnosis in the computed tomography era. Surg Neurol 68:676–681. 10.1016/j.surneu.2006.11.048 Wu X, Jin Y, Zhang X (2014) Intraparenchymal hematoma caused by rupture of the traumatic pseudoaneurysm of middle meningeal artery. J Craniofac Surg 25:e111–113. 10.1097/scs.0000000000000450 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4856100","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":347681442,"identity":"19ccb2a3-7274-441c-a60e-12985dafbfed","order_by":0,"name":"Chen-Ting Cheng","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chen-Ting","middleName":"","lastName":"Cheng","suffix":""},{"id":347681443,"identity":"5c363a2c-e266-4b2b-93f7-048d2775411c","order_by":1,"name":"Cheng-Di Chiu","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cheng-Di","middleName":"","lastName":"Chiu","suffix":""},{"id":347681444,"identity":"b2858b0c-f7b5-469e-8e57-ee43ec10017b","order_by":2,"name":"Wei-Liang Chen","email":"","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wei-Liang","middleName":"","lastName":"Chen","suffix":""},{"id":347681445,"identity":"7c7507e8-d196-4deb-99e5-4c70ca4aacdc","order_by":3,"name":"Jeng-Hung Guo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYHACNgYeAzY5fvbmA0COhAyRWgr4jCV7jiWAtPAQqeWDXOKGGzkGIB5hLfzTzpg9eGNgxgjU8vnVjRoLHgb2w0c34NMicTvH3HCOQRqz5Jm326xzjgEdxpOWdgOfFgPpHDNpHoNjbHzHc7cZ57ABtUjwmBGj5T8Pw4GcZ8Y5/4jXwiYhcCKH+XFuGxFaJG6nlUnOMWAzAAayGXNunwQPGyG/8M9O3ibx5g9bfT978+PPOd/qgHF6+BheLciATQJMEqscBJg/kKJ6FIyCUTAKRg4AAJcXQ/CLx+v8AAAAAElFTkSuQmCC","orcid":"","institution":"China Medical University Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jeng-Hung","middleName":"","lastName":"Guo","suffix":""}],"badges":[],"createdAt":"2024-08-04 09:03:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4856100/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4856100/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64320332,"identity":"8b6fb093-ac63-401b-bb73-3e258df90a93","added_by":"auto","created_at":"2024-09-11 15:20:07","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154750,"visible":true,"origin":"","legend":"\u003cp\u003eInitial brain CT scan revealed (A) minimal SDH and IPH in the right temporal, little pneumocephalus, and (B) linear fracture in the right temporal rim (black arrow).\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4856100/v1/5202f6b431b75e6d858e973d.jpg"},{"id":64320330,"identity":"a6a188f4-3d1e-4e53-aefa-0f83fa528aed","added_by":"auto","created_at":"2024-09-11 15:20:07","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":201929,"visible":true,"origin":"","legend":"\u003cp\u003eBrain CT scan revealed (A) a hypodense round lesion within the hematoma and (B) a hyperdense round lesion with contrast enhancement (black arrow). A pseudoaneurysm formation was suspected.\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4856100/v1/bd9a09bcf50d4c2b016b017d.jpg"},{"id":64320331,"identity":"a9fb8c51-e595-49fe-a232-85548763e29c","added_by":"auto","created_at":"2024-09-11 15:20:07","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":128876,"visible":true,"origin":"","legend":"\u003cp\u003eRight CCA angiogram showed MMA pseudoaneurysm formation, measuring 14.53mm × 12.02mm.\u003c/p\u003e","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4856100/v1/d3f10bb2d3ab0201b5567f0f.jpg"},{"id":64321940,"identity":"93f90e9e-a302-4b3e-9985-5b13099d199b","added_by":"auto","created_at":"2024-09-11 15:36:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":807773,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4856100/v1/c8634810-6a83-49bd-a463-27132b8e8ecc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delayed temporal intraparenchymal hemorrhage caused by rupture of middle meningeal artery pseudoaneurysm after a temporal rim fracture","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntracranial pseudoaneurysms account for less than 1% of all intracranial aneurysms and are mostly caused by traumatic head injuries. Middle meningeal artery (MMA) pseudoaneurysms account for 27% of all traumatic intracranial aneurysms and have a high mortality rate.\u003csup\u003e[4,10]\u003c/sup\u003e It is hypothesized that temporal base fractures cause all three vessel layer injuries of the MMA. The formation of a pseudoaneurysm begins with a whole layer defect of the vessel wall that is sealed by blood clots and the surrounding connective tissues.\u003csup\u003e[8,10]\u003c/sup\u003e Rupture of an MMA pseudoaneurysm usually occurs soon after a trauma event and causes epidural hemorrhage or subdural hemorrhage.\u003csup\u003e[8]\u003c/sup\u003e To early diagnosis, researchers have found two computed tomography image features of MMA pseudoaneurysm, including (1) temporal rim fracture and (2) nearby hemorrhage.\u003csup\u003e[5,9,10]\u003c/sup\u003e Herein, we present a case in which the images fit both features. An MMA pseudoaneurysm was diagnosed using digital subtraction angiography (DSA) and subsequently treated concomitantly with surgery.\u003c/p\u003e"},{"header":"Illustrative Case","content":"\u003cp\u003eA 57-year-old male without a specific medical history was transferred to our emergency department after a motorcycle-to-motorcycle collision. He was comatose with bilateral pupil dilatation to 4.0 mm without light reactivity. Initial brain CT tomography revealed minimal right temporal subdural hematoma and intraparenchymal hemorrhage (IPH), slight pneumocephalus, and a right temporal rim linear fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Emergency surgery of the ICP monitor was performed and revealed 3 mmHg initially. After the surgery, the patient was transferred to the intensive care unit for further treatment. His consciousness gradually improved after two days, and he was successfully extubated on postoperative day 7.\u003c/p\u003e \u003cp\u003eHowever, on the 13th day after the trauma event, during the rehabilitation program, his consciousness suddenly dropped to GCS E1V2M5. The right pupil was dilated to 4.0 mm without a light reflex. A brain CT scan was rearranged and revealed right temporal delayed IPH with uncal herniation and a midline shift of 7 mm to the left. CT with contrast enhancement revealed a round spot lesion within the hematoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A pseudoaneurysm originating from the rupture of the right MMA was suspected. Cerebral DSA confirmed the diagnosis of a right MMA pseudoaneurysm, measuring 14.53 mm \u0026times; 12.02 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe performed a right question-mark craniotomy. The right MMA pseudoaneurysm shell was excised and sent for pathological examination to confirm the diagnosis. The proximal MMA was then coagulated. A hematoma of approximately 50 mL was removed from the right temporal lobe. The brain was soft after hematoma evacuation, and the final intracranial pressure was 4 mmHg. The patient\u0026rsquo;s consciousness gradually recovered to E4V4M6 with occasional irrelevant speech and a requirement for long-term daily care. The patient was transferred to the rehabilitation ward in stable condition, and his modified Rankin scale (mRs) score was 3 after two months.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMMA pseudoaneurysms are mostly caused by traumatic head injury and have a high mortality rate (20%).[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] It is postulated that temporal skull rim fracture can injure the artery and is considered a major risk factor. Additionally, 70\u0026ndash;90% of MMA pseudoaneurysms are related to bony fractures crossing the MMA in the temporal region.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] A hypodense spot within the hematoma close to the temporal base on the CT scan is a definite indicator of pseudoaneurysm formation but is only observed in a few cases.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Researchers have advocated the routine use of computed tomography angiography (CTA) in patients with two predictors ((1) temporal base fracture and (2) nearby hemorrhage) to detect MMA lesions early.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe incidence of MMA pseudoaneurysms may have been underestimated. De Andrade et al.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] collected the angiographic characteristics of 24 patients presenting with a small epidural hematoma and bony fracture crossing the MMA trajectory after a traumatic event. The results demonstrated that seven patients (29.1%) developed MMA pseudoaneurysms, and 17 patients (70.1%) presented with active MMA bleeding and contrast extravasation. They performed MMA embolization in every patient, and a follow-up brain CT scan did not reveal any hematoma enlargement. Although most MMA lesions are benign and regress without treatment, delayed or 2nd rupture could lead to severe morbidity. This study illustrates the epidemiology of MMA pseudoaneurysms and successfully prevents further deterioration.\u003c/p\u003e \u003cp\u003eThe mechanism by which a delayed rupture causes IPH remains unclear. Some studies have postulated that enlargement of the pseudoaneurysm makes the dura mater thinner and thus bleeds into the brain parenchyma.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] We searched for delayed MMA pseudoaneurysms leading to IPH in the literature and summarized all nine cases (including ours) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] The average age of patients with delayed MMA pseudoaneurysms was 54 years. There appeared to be a predominance of men. The initial presentation on CT was a subdural hematoma. The median duration of delayed hemorrhage was 20 days (range, 7\u0026ndash;11 months), and the patient rebled on the 13th day. Most ICH sites are located in the temporal lobe. These patients did not undergo CTA until neurological deterioration occurred. A craniotomy for hematoma evacuation was performed, and the MMAs were coagulated, clipped, or embolized. The reasons for selecting direct surgical treatment were as follows: (1) acute onset of comatose status, (2) right temporal delayed hemorrhage with herniation requiring evacuation, and (3) right pupil dilated to 4.0 mm without a light reflex. Eventually, five patients experienced poor neurological outcomes (mRS\u0026thinsp;\u0026gt;\u0026thinsp;3). Therefore, Montanari et al. suggested arranging CTA 7\u0026ndash;10 days after a traumatic episode in cases with two coexisting predictors to prevent undesirable outcomes.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of nine cases of delayed MMA pseudoaneurysm formation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAuthors \u0026amp; years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHemorrhage on first CT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003cp\u003efracture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDelayed time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eICH site\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePouyanne et al.\u003c/p\u003e \u003cp\u003e1959[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSevere disability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKia-Noury\u003c/p\u003e \u003cp\u003e1961[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSicat et al.\u003c/p\u003e \u003cp\u003e1975[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDeath due to pneumonia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRoski et al.\u003c/p\u003e \u003cp\u003e1982[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFrontal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEmbolization then operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAoki et al.\u003c/p\u003e \u003cp\u003e1992[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVegetative status\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingh et al.\u003c/p\u003e \u003cp\u003e2006[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFrontal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWu et al.\u003c/p\u003e \u003cp\u003e2014[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRecovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMontanari et al 2018[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDeath due to bedridden\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOur case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSDH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTemporal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSevere disability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eNR: Not-Recorded\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIntracranial pseudoaneurysm formation after a traumatic episode has been considered a grade 3 blunt cerebrovascular injury (BCVI) according to the Denver grading scale.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] In the expanded Denver screening guideline, the patient should undergo CTA for either symptoms or signs of BCVI presentation. Since skull fracture is almost always related to MMA pseudoaneurysm formation, it can be detected in the early phase of a differential diagnosis is considered. According to the new Denver Health Medical Center BCVI screening guidelines, the initial negative CTA findings require further investigation, except when there is a high suspicion. Hence, due to the underestimated prevalence of MMA pseudoaneurysms, we recommend initial CTA screening and/or follow-up with cerebral DSA after 7\u0026ndash;10 days in patients with temporal base fractures and nearby hemorrhages.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe describe a case of delayed MMA pseudoaneurysm rupture leading to IPH, with an initial presentation of two predictors of MMA pseudoaneurysm formation. Careful reading of the initial CT scan and repeating CTA or cerebral DSA 7\u0026ndash;10 days later in patients with skull base fractures and nearby hemorrhages can prevent this critical complication.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical\u003c/strong\u003e \u003cstrong\u003eApproval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is limited to description of the clinical course, outcomes of an individual patient without conducting research or involving interventions beyond standard care. The requirement for approval from the institutional review board is then waived for case reports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting\u003c/strong\u003e \u003cstrong\u003einterests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCharlton Chen-Ting, Cheng conceptualized the study\u0026nbsp;and wrote the main manuscript\u003cbr\u003e\u0026nbsp;Wei-Liang, Chen provided neuroradiological interpretation\u0026nbsp;\u003cbr\u003e\u0026nbsp;Cheng-Di Chiu is the reviewer and supervisor of the manuscript, image, tables and the literatures\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCorrespondence to Jeng-Hung Guo\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability\u003c/strong\u003e \u003cstrong\u003eof data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAoki N, Sakai T, Kaneko M (1992) Traumatic aneurysm of the middle meningeal artery presenting as delayed onset of acute subdural hematoma. 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J Craniofac Surg 25:e111\u0026ndash;113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/scs.0000000000000450\u003c/span\u003e\u003cspan address=\"10.1097/scs.0000000000000450\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"trauma, pseudoaneurysm, middle meningeal artery, blunt cerebrovascular injury, fracture","lastPublishedDoi":"10.21203/rs.3.rs-4856100/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4856100/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMiddle meningeal artery (MMA) pseudoaneurysms are mostly caused by traumatic brain injury and can lead to severe morbidity because of epidural or subdural hematoma. We present a rare case of delayed rupture of a right MMA pseudoaneurysm that caused a temporal intraparenchymal hemorrhage (IPH). Delayed rupture of an MMA pseudoaneurysm is rare but has devastating consequences. Digital subtraction angiography in patients with traumatic brain injury with temporal rim fracture and temporal IPH may help diagnose this lesion easily and treat the disease earlier.\u003c/p\u003e","manuscriptTitle":"Delayed temporal intraparenchymal hemorrhage caused by rupture of middle meningeal artery pseudoaneurysm after a temporal rim fracture","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-11 15:20:02","doi":"10.21203/rs.3.rs-4856100/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a0188107-86a8-4bec-8ec7-d4773c846b30","owner":[],"postedDate":"September 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-11T15:20:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-11 15:20:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4856100","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4856100","identity":"rs-4856100","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}