traumatic aneurysms of the middle meningeal artery ( mma ) are rare occurrences that are usually associated with an underlying skull fracture4 ) , which comprise less than 1% of all intracranial aneurysms3,15 ) . most of these aneurysms are actually false aneurysms , or pseudoaneurysms , which are caused by the rupture of entire vessel wall layers , with the wall of the aneurysm being formed by the surrounding cerebral structures10 ) . acute or delayed epidural hematoma is the most frequent presentation of traumatic pseudoaneurysms10,15 ) , but it can be associated with subdural , subarachnoid , or even intracerebral hematoma1,4 ) . because of a high mortality rate ( 20% ) they should be recognized early . on the other hand , spontaneous resolution the simple presence of a pseudoaneurysm is an indication for intervention or surgery is also unclear and there are no definite treatment guidelines . we report a case of patient with angiographical progressive change of traumatic pseudoaneurysm for one week and discuss natural course and treatment guidelines . a 47-year - old woman with diabetes mellitus presented to the emergency department of our hospital with head and facial injury . the patient was found in collapsed state in the street and could not remember anything . on admission , her mental status was drowsy with glasgow coma scale ( gcs ) score of 13/15 . the 3rd nerve palsy signs of ptosis , extraoculor movement ( eom ) limitation and non reactive pupil were shown in left eye . initial brain computed tomography ( ct ) revealed a skull fracture , epidural hematoma without mass effect in the right hemisphere and subarachnoid hemorrhage in both sylvian fissures and basal cistern , which were more dominant in left side ( fig . 1 ) . the ct angiogram revealed an aneurysm of right middle cerebral artery bifurcation . we think this one was unruptured aneurysm , because dominance of subarachnoid hemorrhage was definite in left sylvian fissure and basal cistern ( fig . 2 ) . the cerebral angiogram was performed to identify the cause of 3rd nerve palsy or other possible vascular abnormality . there is no intracranial vascular lesion , but two pseudoaneurysms arising from the right mma adjacent to the fracture line of temporal bone were found ( fig . this mma pseudoaneurysm was presumed to be related to the temporal bone fracture and was probably the cause of the epidural hematoma . after 1 week , cerebral angiogram was repeated to re - evaluate the pseudoaneurysm and to determine the treatment plan . the initially found distal pseudoaneurysm is collapsed , and another aneurysm was found more aggravating appearance ( fig . in addition , the prognosis in traumatic pseudoaneurysms has been reported to be generally poor , immediately , the treatment was planned . the right external carotid artery and then the posterior branch of right mma the amount of histoacryl was 0.5 cc , and the ratio of histoacryl and lipiodol was 1 : 3 . after embolization , selective injections of the right external carotid artery and the right mma showed normal filling of the mma except posterior branch and no filling of the pseudoaneurysm ( fig . the patient was discharged from the hospital with no neurologic deficits except 3rd nerve palsy . a 3-month follow - up , ptosis and eom was mild improved and ct showed complete resolution of epidural hematoma . a 70-year - old woman presented to the emergency department of our hospital with head injury . the patient slipped down in the street and had loss of consciousness . on admission , the patient with scalp contusion was alert and gcs score was 15/15 without any neurologic deficit . initial brain ct revealed a skull fracture , epidural hematoma without mass effect in the left temporal area ( fig . there were right vertebral artery stenosis , and a pseudoaneurysm arising from the left mma ( fig . 8) . after 1 week , we performed cerebral angiogram to re - evaluate the pseudoaneurysm and determine the treatment plan . 9 ) , need to be treated . we catheterized the left external carotid artery then the posterior branch of left mma . the amount of histoacryl was 0.5 cc , and the ratio of histoacryl and lipiodol was 1 : 3 . after embolization , selective injections of the left external carotid artery and the left mma showed normal filling of the mma except posterior branch , and no filling of the pseudoaneurysm ( fig . the patient was discharged with no neurologic deficits , and a 2-month follow - up , the brain ct showed much resolved epidural hematoma . a 47-year - old woman with diabetes mellitus presented to the emergency department of our hospital with head and facial injury . the patient was found in collapsed state in the street and could not remember anything . on admission , her mental status was drowsy with glasgow coma scale ( gcs ) score of 13/15 . the 3rd nerve palsy signs of ptosis , extraoculor movement ( eom ) limitation and non reactive pupil were shown in left eye . initial brain computed tomography ( ct ) revealed a skull fracture , epidural hematoma without mass effect in the right hemisphere and subarachnoid hemorrhage in both sylvian fissures and basal cistern , which were more dominant in left side ( fig . 1 ) . the ct angiogram revealed an aneurysm of right middle cerebral artery bifurcation . we think this one was unruptured aneurysm , because dominance of subarachnoid hemorrhage was definite in left sylvian fissure and basal cistern ( fig . 2 ) . the cerebral angiogram was performed to identify the cause of 3rd nerve palsy or other possible vascular abnormality . there is no intracranial vascular lesion , but two pseudoaneurysms arising from the right mma adjacent to the fracture line of temporal bone were found ( fig . this mma pseudoaneurysm was presumed to be related to the temporal bone fracture and was probably the cause of the epidural hematoma . after 1 week , cerebral angiogram was repeated to re - evaluate the pseudoaneurysm and to determine the treatment plan . the initially found distal pseudoaneurysm is collapsed , and another aneurysm was found more aggravating appearance ( fig . in addition , the prognosis in traumatic pseudoaneurysms has been reported to be generally poor , immediately , the treatment was planned . the right external carotid artery and then the posterior branch of right mma the amount of histoacryl was 0.5 cc , and the ratio of histoacryl and lipiodol was 1 : 3 . after embolization , selective injections of the right external carotid artery and the right mma showed normal filling of the mma except posterior branch and no filling of the pseudoaneurysm ( fig . the patient was discharged from the hospital with no neurologic deficits except 3rd nerve palsy . a 3-month follow - up , ptosis and eom was mild improved and ct showed complete resolution of epidural hematoma . a 70-year - old woman presented to the emergency department of our hospital with head injury . the patient slipped down in the street and had loss of consciousness . on admission , the patient with scalp contusion was alert and gcs score was 15/15 without any neurologic deficit . initial brain ct revealed a skull fracture , epidural hematoma without mass effect in the left temporal area ( fig . there were right vertebral artery stenosis , and a pseudoaneurysm arising from the left mma ( fig . 8) . after 1 week , we performed cerebral angiogram to re - evaluate the pseudoaneurysm and determine the treatment plan . the amount of histoacryl was 0.5 cc , and the ratio of histoacryl and lipiodol was 1 : 3 . after embolization , selective injections of the left external carotid artery and the left mma showed normal filling of the mma except posterior branch , and no filling of the pseudoaneurysm ( fig . the patient was discharged with no neurologic deficits , and a 2-month follow - up , the brain ct showed much resolved epidural hematoma . aneurysms of the mma are very rare phenomena and known to be of 2 types : the true aneurysm and the pseudoaneurysm4 ) . the true aneurysm is usually accompanied with other pathologic conditions such as paget disease , hypertension , meningioma , and dural arteriovenous malformations and has the same histologic characteristics that is presented in intracranial cerebral aneurysms6,13,14,16 ) . pseudoaneurysms , on the other hand , are associated with a head trauma causing a tear in the arterial wall in most cases4 ) . about 70 - 90% of cases of traumatic mma pseudoaneurysm are associated with a fracture crossing the mma or one of its two branches in the temporal region7 ) . in a histologic perspective , there is only fibroconnective tissue or hematoma surrounding , covered the hole in the wall , thus forming a pseudoaneurysm . traumatic pseudoaneurysms show specific characteristics on angiography , which include peripheral location , absence of neck , sometimes irregular shape . its filling and emptying are delayed and very slow during angiogram , which means that the contrast medium has time to settle at the bottom of the aneurysm and the pre- and post - aneurysmal segments of the meningeal artery are not opacified at the same time . these features explain why traumatic meningeal pseudoaneurysms are usually visible only in the late injection stages of selective external carotid angiography5,8,9 ) . usually , meningeal pseudoaneurysms are known to present with acute or delayed epidural hematoma , but occasionally , they can also be associated with subdural , subarachnoid , or intracerebral hemorrhage1,4 ) . but in some reports , progressive change of traumatic aneurysms has been demonstrated on repeated angiograms8,11 ) . spontaneous thrombosis of mma pseudoaneurysm is a rare event that has been reported before by namba et al.12 ) one possible mechanism of progressive change is that initially , a small tear which is not large enough to result in an epidural hematoma is occurred in the meningeal artery . and formation of clot that contains further leakage of blood is created , then recanalize and form a false lumen . this pseudoaneurysm tends to be ruptured in a delayed fashion , resulting in an intracranial hematoma and clinical deterioration . this series of events has been reported with meningeal pseudoaneurysms in which the patients typically recovered completely after the initial trauma but deteriorated clinically in a delayed fashion from secondary rupture of the pseudoaneurysm after initial tear of the arterial wall2,5 ) . based on review of literatures , the simple presence of a pseudoaneurysm is an indication for intervention or surgery is also unclear . because only a few cases of mma pseudoaneurysms has been reported in the literature and the incidence of incidental pseudoaneurysms is essentially unknown , there are no definite treatment guidelines , yet . some authors recommend that treatment be carried out without any delay because of the risk of secondary rupture4 ) . some author presented spontaneous thrombosis of pseudoaneurysm17 ) . in our patients , conservative management and observation were performed for the one week and then the pseudoaneurysms were re - evaluated on conventional angiogram ; however , revealed that the one pseudoaneurysm changed more aggravating appearance and the other was only mildly improved . we carefully think that the aggravating change or rupture risk is higher than spontaneous thrombosis . in addition , the prognosis in traumatic pseudoaneurysms has been reported to be generally poor . therefore , considering the risk of a secondary rupture and poor prognosis , we suggest that the treatment of traumatic pseudoaneurysms should be performed without delay . although the incidence of traumatic mma pseudoaneurysm is rare , it should be considered possibility of meningeal pseudoaneurysms in cases of head trauma , especially if the fracture crosses the expected location of the middle meningeal artery . because this pseudoaneurysm may have aggravating course and secondary bleeding , we suggest it should be treated as soon as possible .
traumatic pseudoaneurysms of the middle meningeal artery ( mma ) are rare phenomenon , which are usually associated with head trauma such as an underlying skull fracture . 
 they were usually known to cause acute or delayed epidural hematomas but can be associated with subdural , subarachnoid , or even intracerebral hemorrhage . 
 sometimes , a high mortality rate was reported in these circumferences . 
 but the natural course of these pseudoaneurysms is not well recognized . 
 the indication and guideline of treatment for pseudoaneurysm are also unclear . 
 this report describes a rare case of angiographically progressive change of traumatic pseudoaneurysm of the middle meningeal artery for one week , which was treated with endovascular embolization .