Montanari Eva, Polonara Gabriele, Montalti Roberto, Vivarelli Marco, Ricciuti Riccardo Antonio, Giorgetti Raffaele, Tagliabracci Adriano
Section of Legal Medicine, Polytechnic University of Marche, Ancona, Italy.
Division of Neuroradiology, Polytechnic University of Marche, Ancona, Italy.
World Neurosurg. 2018 Sep;117:394-410. doi: 10.1016/j.wneu.2018.06.158. Epub 2018 Jun 30.
Traumatic pseudoaneurysm of the middle meningeal artery (PMMA) is rare. Its rupture is associated with high mortality, so an early diagnosis is recommended for this risky condition. In the absence of a specific guideline, computed tomography (CT), digital subtraction angiography, and CT angiography (CTA) are proposed for its diagnosis. CTA is the technique of choice even if it is almost never performed, especially in mild head injury. We report a rare case of a delayed rupture of PMMA, analyzed from a forensic point of view.
Fifteen days after mild blunt head trauma, characterized by temporal fracture and a small hemorrhage near the rim, a wide intraparenchymal hemorrhage (IPH) occurred. The onset of IPH was marked by neurologic deterioration and arm paralysis. Immediate head CT showed IPH, and CTA showed PMMA. Prompt surgery could not help patient survival. The goal of autopsy was to formulate the cause of death and to individuate potential medical negligence.
In the literature, 16 cases of 54 are related to PMMA (26%) and are associated with IPH. IPH can be acute or delayed. Eight cases of acute IPH and 8 cases of delayed IPH (including our case), both coexisting with PMMA, are described. The literature review showed that the association of temporal rim fracture and a small hemorrhage nearby is highly predictive of PMMA formation.
Therefore, in the presence of these 2 risk factors after heat trauma, CTA is strongly suggested.
外伤性脑膜中动脉假性动脉瘤（PMMA）较为罕见。其破裂与高死亡率相关，因此对于这种高危情况建议早期诊断。在缺乏具体指南的情况下，推荐采用计算机断层扫描（CT）、数字减影血管造影和CT血管造影（CTA）进行诊断。CTA是首选技术，即便其几乎从未被应用，尤其是在轻度头部损伤的情况下。我们从法医角度报告一例罕见的PMMA延迟破裂病例。
轻度钝性头部外伤15天后，表现为颞骨骨折及骨折边缘附近小出血，随后发生广泛的脑实质内出血（IPH）。IPH的发生以神经功能恶化和手臂麻痹为特征。即刻头颅CT显示IPH，CTA显示PMMA。及时手术未能挽救患者生命。尸检目的是明确死因并确定潜在的医疗过失。
文献中，54例中有16例与PMMA相关（26%）且伴有IPH。IPH可为急性或延迟性。本文描述了8例急性IPH和8例延迟性IPH（包括我们的病例），均与PMMA并存。文献回顾表明，颞骨骨折边缘及附近小出血的关联高度提示PMMA形成。
因此，热损伤后存在这两个危险因素时，强烈建议行CTA检查。
