British Journal of Radiology (2003) 76, 746-749
© 2003 British Institute of Radiology
doi: 10.1259/bjr/98542646
Percutaneous puncture and pre-operative cyanoacrylate obliteration of a traumatic false aneurysm of an angular artery branch
F Huang, MD
1
Y-L Kuo, MD
2
S-F Ko, MD
2
S-H Ng, MD
2
C-C Lui, MD
2 and
S-F Jeng, MD
1
Departments of 1 Plastic Surgery and 2 Radiology, Chang Gung University, Chang Gung Memorial Hospital, 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien 833, Taiwan
Correspondence: Sheung-Fat Ko
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Abstract
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We report a case of traumatic false aneurysm developed in the right glabella in a 5-year-old boy 3 weeks after an innocuous fall. Ultrasound, CT and facial arteriography did not reveal the feeding artery. After direct puncture of the glabellar bulge and rapid aspiration of blood, percutaneous contrast agent infusion revealed that the false aneurysm was supplied by the contralateral angular artery. Intralesional obliteration with cyanoacrylate was subsequently performed smoothly. Succeeding excision was easy and the cosmetic outcome was excellent.
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Introduction
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Traumatic artery aneurysms of the face and temple are uncommon [1–6]. In a large series review of 387 cases, 327 affected the superficial temporal artery, 27 affected the internal maxillary artery, 26 affected the facial artery, 2 each affected the lingular artery, occipital artery and superior thyroid artery, and 1 affected the supraorbital artery [1]. To our knowledge, a false aneurysm (FA) of the angular artery has not been previously reported. We describe such a case with inconclusive findings on ultrasound, CT and selective facial angiography. We believe that it may be ascribed to the increased pressure in the FA sac built up by pooling blood with resultant blockade of further inflow of contrast agent, the so-called "fluid-block" effect [1]. Percutaneous injection of contrast agent into the glabella lesion after aspiration of the bloody contents revealed a FA sac supplied by the contralateral angular artery branch. Subsequent intralesional cyanoacrylate obliteration facilitated succeeding surgery.
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Case report
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A 5-year-old boy was brought to the Plastic Surgery outpatient clinic due to development of an elastic nodule on the forehead 3 weeks after an accidental fall with his forehead hitting the ground. Physical examination showed a 3 x 2.5 cm, non-pulsatile, reddish, tender nodule protruding from the right side of the glabella with some surrounding ecchymosis. No thrill or bruit was detected on auscultation with a stethoscope. Ultrasound revealed a heteroechoic mass with some cystic components. Doppler scan (Aspen advanced, Acuson, Mountain View, CA), with a sector transducer with frequency 10 MHz after optimization for low flow rates with the gain set to the highest possible overall level without the introduction of any significant noise, revealed neither obvious vascular flow nor any surrounding dilated vessel. A haematoma was initially suspected. Direct needle aspiration yielded 4 ml of bloody fluid. However, the lesion resumed its original size about 1 min later, suggesting the presence of a vascular lesion. Enhanced CT revealed a hypodense nodule with an eccentrically enhanced dot in the subcutaneous layer of the glabella (Figure 1a
). No associated fracture or intracranial lesion was noted. Correlating the CT finding with the history of recent trauma, a traumatic FA was suspected. Compression was tried but failed due to pain. Under general anaesthesia, angiography was performed and bilateral carotid arteriograms appeared normal. Selective bilateral superficial temporal, internal maxillary and facial angiograms also did not reveal any vascular abnormality. Under fluoroscopic guidance, direct percutaneous puncture of the lesion with a 20 G intravenous catheter (BD Insyte, Beckton Dickinson Infusion Therapy Systems, Sandy, UT) was performed and slow contrast agent infusion revealed contrast retention within the lesion without vascular enhancement. We then performed another intralesional contrast injection immediately after rapid aspiration of the retained contrast agent and bloody contents. A FA sac fed by the contralateral left angular artery was then clearly demonstrated (Figures 1b, c). After discussion with the plastic surgeons, we performed intralesional embolisation with adhesive glue, by using a mixture of n-butyl-2-cyanoacrylate (NBCA) (B. Braun, Tuttlingen, Germany) and lipiodal (Guebert, Aulnay-sous-Bois, France) in a 1:4 ratio, in order to reduce blood loss and to minimize the incision wound in subsequent surgery. After a total of 2.5 ml of NBCA/lipiodal mixture had been applied manually via the 20 G catheter under fluoroscopic guidance, optimal casting of the FA sac was achieved (Figure 1d). Follow-up angiography revealed patency of the bilateral angular arteries. 1 week after the embolisation, the glabellar lesion became painless with a moderate regression in size, 2 x 1.8 cm, and the overlying skin resumed its normal colour. Follow-up brain CT revealed almost complete filling of the FA sac with the retained NBCA/lipiodal mixture (Figure 1e). 3 days later, complete excision of the embolised lesion was easily performed via a small skin incision, with blood loss of less than 3 ml and not requiring vessel ligation. Pathological examination revealed a FA with foreign body materials and small amount of blood clot enclosed by a fibrous pseudocapsule. The child was well at 1-year follow-up with an excellent cosmetic outcome.
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Figure 1. (a) Enhanced CT shows a 2.5 cm hypodense mass (white arrow) with an eccentric, enhanced spot (arrowhead) in the subcutaneous tissue over the right glabella. (b) Anteroposterior and (c) lateral radiographs of intralesional contrast agent injection after aspiration of the bloody content show a false aneurysmal sac (long arrows) and retrograde opacification of the contralateral angular artery (short arrows). (d) Follow-up radiograph immediately after application of NBCA/Lipiodal mixture reveals satisfactory casting of the false aneurysmal sac (arrow). (e) Follow-up CT reveals moderate regression of the false aneurysm (arrow) which is almost fully occupied by the emboliser.
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Discussion
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Traumatic aneurysms result from partial disruption of the arterial wall, with the adjacent blood-filled space gradually being enclosed by a fibrous pseudocapsule or forming an out-pouching of the vascular wall involving the intima, media and adventitia, leading to false or true aneurysms, respectively [1, 2]. Traumatic aneurysms of the face and temple are uncommon as most vessels in these areas are generally well buffered by overlying soft tissues. Nonetheless, these vessels become vulnerable to injury when they approach the surface or cross bony structures [1]. The facial artery is usually jeopardized by blunt facial trauma at the inferior margin of the lower jaw [1, 5]. While most of the reported aneurysms of the superficial temporal artery are caused by traumatic assaults, those of the internal maxillary artery are predominately caused by iatrogenic events [1–4]. Although the angular artery crosses the nasion just underneath the skin, vascular injury to the angular artery has not been previously described, possibly due to the fact that it is well protected by the protruding forehead, nose and cheeks from trauma [1–4]. Nevertheless, our case documents that direct blunt trauma to the forehead in a young child with the relatively flattened forehead, nose and cheeks may lead to vascular insult of the angular artery branches and the subsequent formation of a FA.
The signs and symptoms of true or false traumatic aneurysms are similar, regardless of location; thus, the diagnosis can usually be made by history and physical examinations. Traumatic aneurysms usually develop about 2 to 8 weeks after trauma, though they may appear at any time [1–4]. A tender mass with discolouration of the overlying skin as well as the presence of a palpable thrill or an audible systolic bruit is typically found at the previously traumatized area [1–4]. However, in our patient, it was difficult to differentiate the aneurysm from a haematoma or an abscess clinically in the absence of a palpable thrill or an audible systolic bruit. Re-expansion of the lesion after aspiration was indicative of active extravasation and thus, an aneurysm was suspected. Under this clinical scenario, imaging studies were important for confirming the diagnosis and identifying the feeding artery.
Doppler ultrasound is a helpful tool for the evaluation of traumatic true or false aneurysms by revealing fusiform dilatation of the native artery or saccular eccentric dilatation, respectively. Turbulent intraluminal flow within the lesion is usually seen [4, 5]. CT is also helpful in the diagnosis of an aneurysm by revealing a round lesion with vascular enhancement and ruling out any associated intracranial pathologic conditions [2, 6]. Though not absolutely necessary, angiography can delineate the anatomic details of the aneurysm. It can also reveal any coexisting arteriovenous fistula or other pathology, which may not be identified clinically [1, 2, 4, 7–10].
This case was unusual in several ways. First, ultrasound failed to demonstrate the typical "to and fro" Doppler flow pattern within the FA. It might be related to exceedingly low arterial inflow, reflected by the CT finding that only a small enhanced spot was seen within the lesion. The irritability of this small boy, due to tenderness of the FA when the ultrasound probe was pressed on the lesion, might have hampered delicate ultrasound examination. Second, selective catheterization of the bilateral internal and external carotid, superficial temporal, and facial arteries also failed to show any vascular abnormality. Even with direct percutaneous puncture and contrast agent injection, only focal accumulation of contrast agent was shown. Third, the FA sac and its arterial supply from the contralateral angular artery branch were only demonstrated during rapid injection of the contrast agent immediately after aspiration of its bloody contents. These confusing imaging features could plausibly be explained by the increased pressure in the FA sac built up by pooling blood that eventually reached an equilibrium status to the feeding artery, holding back further arterial or contrast agent influx—the so-called "fluid-block" effect [1].
The natural history of facial true or false aneurysms is still unknown. To our knowledge, no criteria for predicting spontaneous thrombosis or resolution of facial aneurysms have been reported. Thus, it was hard to foretell that the FA in this small body would thrombose if left untreated. On the other hand, as in this case, the indications for intervention of traumatic facial FA aim to reduce the risk of subsequent rupture and haemorrhage to relieve headache or local tenderness, and to resolve cosmetic defects [1–4]. Conservative treatment with compression is the simplest method [1, 2], but was unsuccessful in our case due to the tenderness of the lesion and the poor co-operation of this young child. For most superficial temporal artery aneurysms, simple excision with proximal and distal ligation of the feeding vessel is generally the treatment of choice [1–4]. Embolisation has also been described as an effective method of treating lesions that are difficult to reach [1, 8–10]. As shown in our case, carotid and facial arteriograms may occasionally fail to reveal the aneurysm. Direct intralesional contrast agent injection after aspiration of the lesion content may offer detailed anatomic demonstration of the aneurysmal sac and its feeding artery. Thus potentially catastrophic surgical blind clamping can be avoided. Various embolisation agents, including autologous clot, absorbable gelatin sponge, polyvinyl alcohol and liquid tissue adhesives, have been used to obliterate aneurysmal blood flow [1, 7–14], and most of them are administered via the transarterial route. Having demonstrated the feeding artery by direct sac injection, it would be possible to perform super-selective angiography using a microcatheter to allow embolisation of the lesion transarterially. However, having considered the tortuous course and small caliber of the distal branch of the angular artery as well as the presence of the potential fluid-block effect of the FA sac, we decided to proceed to obliteration of FA via direct puncture. Coagulation of peripheral or visceral aneurysms by direct percutaneous injection or transarterial approach with thrombin has been reported but this embolic agent has the potential for inadvertent embolisation [15]. Direct puncture embolisation of arteriovenous fistula of the scalp, mandibular intraosseous arteriovenous malformation, orbitofacial or cutaneous vascular malformation with tissue adhesive have been described with acceptable results [11–14]. It has also been shown that the 1:4 ratio of NBCA/lipiodal mixture would allow slow and careful application under fluoroscopic guidance without rapid casting of the puncture catheter [16]. Our case illustrates that pre-operative direct puncture obliteration of the angiographically occult glabellar FA sac was useful. Satisfactory obliteration of the FA with preservation of the native feeding artery and prevention of inadvertent embolisation of tissue adhesive into the circulation could be achieved while the resulting hard but avascular mass made surgical excision easier. In addition to shrinkage of the lesion and relief of tenderness, successful obliteration of the lesion and closure of the communication with its parent artery facilitated surgical excision. Only a small incision without any arterial ligation was performed, and the operating time was short. Most importantly, the cosmetic outcome was excellent for this young child.
Received for publication September 18, 2002.
Revision received January 10, 2003.
Accepted for publication February 13, 2003.
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Abstract
Introduction
