Iatrogenic pseudoaneurysm of the superficial temporal artery following craniectomy from a scalp hook retractor penetrating injury: Case report and literature review

Abstract

Background Iatrogenic pseudoaneurysms in scalp vessels are an uncommon complication after cranial surgery. This paper reports a case of scalp pseudoaneurysm in the superficial temporal artery (STA) after forceful hook retraction in craniectomy and reviews the relevant literature. Case description A 36-year-old man with history of hypertension and depression presented to the emergency department with head injury after using sedation medication. Brain computed tomography (CT) revealed a 2-cm-thick right parietal extradural hematoma (EDH) with parietal skull fracture, a bilateral lower frontotemporal contusional intracerebral hematoma, diffuse subarachnoid hemorrhage, and a right frontotemporoparietal subdural hematoma. To prevent EDH progression, frontotemporal emergency craniectomy to remove the EDH was performed. The next day, a firm, painful mass measuring 3 × 3.5 cm 2 was discovered over the right frontal scalp. The mass was close to the site where the scalp hook retractor had been placed during surgery. Sonography revealed pulsatile blood flow with an arterial feeder inside the mass. CT angiography revealed a 1 × 1.2 × 0.7 cm 3 pseudoaneurysm in the right frontal scalp from the frontal branch of the STA. We scheduled a resection of the pseudoaneurysm and combined cranioplasty on the 29th postoperative day. The pseudoaneurysm was resected en bloc. The patient was discharged with clear consciousness and intact muscle power. Conclusion The complications of STA pseudoaneurysms caused by scalp hook retractors are rare and not yet well reported. Surgeons must avoid injuring the STA when using a scalp hook retractor.

Pathological Findings of Donor Vessels in Bypass Surgery

“…Several reports highlighted the occurrence of iatrogenic pseudoaneurysms in different scenarios. Zheng et al reported iatrogenic pseudoaneurysms of the STA resulting from vessel penetration with a needle or hook, or injury to the vessel wall during craniotomy [24]. Protecting vessels during harvesting and conducting thorough imaging evaluations postbypass surgery are emphasized, as illustrated by a past case where pseudoaneurysm rupture after STA-MCA anastomosis caused massive intracerebral hemorrhage [25].…”

A Case of Pseudoaneurysm of the Superficial Temporal Artery Causing a Massive Subcutaneous Hematoma after Craniotomy

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Reported causes of STA damage include subcutaneous suture needles, hook retractor, or three-point pin fixators. [6][7][8]13,16 Systemic diseases including hemophilia or vasculitis, and background such as triple H therapy after subarachnoid hemorrhage, are also risk factors for pseudoaneurysms. 6,9,11,12 Furthermore, even if there is only endothelial damage without bleeding, surgical manipulation or electrocoagulation may lead to formation of fusiform dilatation and subsequent minor bleeding, resulting in pseudoaneurysm formation.…”

“…Reports of pseudoaneurysms after craniotomy are rare, with only 16 cases in the literature (►Table 1). [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Reported causes of STA damage include subcutaneous suture needles, hook retractor, or three-point pin fixators. [6][7][8]13,16 Systemic diseases including hemophilia or vasculitis, and background such as triple H therapy after subarachnoid hemorrhage, are also risk factors for pseudoaneurysms.…”

“…A superficial temporal artery (STA) pseudoaneurysm after a craniotomy is rare, with only 16 cases reported in the literature -the majority of these were found in subcutaneous pulsatile and painless masses. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Herein, we report a case of an STA pseudoaneurysm with severe subcutaneous bleeding after craniotomy, and provide a review of the literature. To our knowledge, only three similar cases have been reported.…”

Single-person Harvest of Anterolateral Thigh Flap Using Scalp Hooks

“…Herein, we present left anterolateral thigh (ALT) flap 2) harvesting using scalp hooks 3) as retractors. The usage of scalp hooks largely addressed the abovementioned concerns, demonstrating their excellent superiority over traditional retractors.…”