A rare case of non post-traumatic aneurysm of occipital artery

A rare case of non post-traumatic aneurysm of occipital artery

224
Audiologia
i foniatria
Otorynolaryngologia
2014,
13(4): 224-227
A rare case of non post-traumatic aneurysm of occipital artery
Rzadki przypadek tętniaka tętnicy potylicznej pochodzenia nieurazowego
Małgorzata Górka 1/, Tomasz Stapiński 1/, Marcin Feldo 2/, Radosław Pietura 3/, Paweł Wołejsza 4/,
Joanna Wrońska 1/, Łukasz Rolniak 1/, Joanna Kosałka 5/
3/
4/
5/
1/
2/
Oddział Otolaryngologii i Otolaryngologii Dziecięcej, Wojewódzki Szpital Podkarpacki im. Jana Pawła II w Krośnie
Klinika Chirurgii Naczyń i Angiologii, Uniwersytet Medyczny w Lublinie
Zakład Elektroradiologii, Uniwersytet Medyczny w Lublinie
Oddział Chirurgii Ogólnej, Onkologicznej i Naczyniowej, Wojewódzki Szpital Podkarpacki im. Jana Pawła II w Krośnie
II Katedra Chorób Wewnętrznych, Oddział Alergii i Immunologii, Szpital Uniwersytecki w Krakowie, Uniwersytet
Jagielloński Collegium Medicum
Tętniaki tętnicy potylicznej są bardzo rzadkie. Przed majem
2013 r. opisanych zostało w literaturze tylko 11 przypadków
tej choroby (w większości były one wynikiem urazu). Autorzy
przedstawili przypadek 54-letniej kobiety rasy kaukaskiej, skarżącej się na bezbolesny, pulsujący guz w okolicy prawego kąta
żuchwy, który pojawił się nagle i nie był spowodowany urazem.
Na podstawie wykonanej angiografii postawione zostało rozpoznanie tętniaka tętnicy potylicznej prawej (w segmencie mięśnia
dwubrzuścowego). W przeciągu 6-miesięcznej obserwacji po
wykonanym zabiegu zaopatrzenia tętniaka nie obserwowano
nawrotu guza. Zgodnie z naszym stanem wiedzy jest to piąty
opisany przypadek tętniaka tętnicy potylicznej niespowodowany
urazem. Obserwacja wskazuje, że prawdopodobnie najlepszą
metodą diagnostyczną tętniaka jest angiografia.
Słowa kluczowe: tętnica potyliczna, tętniaki, angiografia,
arteriografia
Aneurysms of occipital artery are very uncommon. Before may
2013, only 11 cases of this disorder (most of them were the
results of trauma) have been reported in the literature. We
report the case of a 54-year-old Caucasian woman presented
with a painless pulsatile scalp mass in the region of right angle
of mandible, which developed rapidly and was not caused by
a trauma. The aneurysm of right occipital artery (in digastrics
segment) was diagnosed by angiography. The patient had no
recurrence of the mass after coil occlusion at six months followup. To the best of our knowledge, this is the fifth reported case
of aneurysm of occipital artery not caused by a trauma. Our
case shows that angiography is probably the best technique for
diagnosing aneurysms of occipital artery.
Keywords: occipital artery, aneurysm, angiography,
arteriography
© Otorynolaryngologia 2014, 13(4): 224-227
Adres do korespondencji / Address for correspondence
www.mediton.pl/orl
Lek. med. Małgorzata Górka
Oddział Otolaryngologii i Otolaryngologii Dziecięcej
Wojewódzki Szpital Podkarpacki im. Jana Pawła II
ul. Korczyńska 57, 38-400 Krosno
tel. 72 790 51 47; e-mail: [email protected]
Abbreviations and acronyms
ANA – anti-nuclear antibodies
ANCA – anti-neutrophil cytoplasmic antibodies
CTA – computer tomography angiography
Introduction
Aneurysms of the occipital artery are unusual,
and in most cases they are described as a consequence
of trauma [1-3]. In the literature this disease was more
frequent in men, and was diagnosed between 2nd and
9th decade of life [3]. These lesions usually manifest
as painless, pulsatile scalp masses [2].
Only 11 cases of aneurysm of the occipital artery
have been previously reported in the literature (7 of
them were caused by a trauma) [2]. We report a 5th
case of aneurysm of occipital artery not caused by
trauma.
Górka M, Stapiński T, Wrońska J, et al. A rare case of non post-traumatic aneurysm of occipital artery
225
Case report
A 54-year old female suffering from irregular
heartbeat and ischialgia was admitted to the hospital with complains of tinnitus on the right side,
trismus and painless, pulsatile mass in the region
of right angle of mandible. The mass has been
­increasing incrementally in size since 2 months. The
patient denied the history of head trauma.
Physical examination revealed the pulsatile,
tenderless mass in the region of the right angle of
mandible which was circular in shape and approximately 20 x 15 mm in diameter. Neurological, rheumatological, ophthalmological, otolaryngological
examinations were normal. Anti-nuclear antibodies
(ANA) and anti-neutrophil cytoplasmic antibodies
(ANCA) were negative. Doppler ultrasonography
confirmed hiperechogenic structure (18 x 12 mm)
with visible blood flow in the region of right angle
of mandible. Angio-CT demonstrated a lesion described as an aneurysm of superficial temporal
artery located in the back of the right ramus of
mandible (in the middle of its high) (Fig. 1). In the
circle of Willis, aorta and aortic branches there were
no pathologies.
After angiosurgical consultation patient was
qualified to the embolization of aneurysm. Angiography of right external carotid artery and its
branches (which was done before operation) revealed
aneurysm of branch of right occipital artery (13 x
10 mm in size) (Fig. 2A,B).
Fig. 1. Aneurysm of occipital artery (arrow), which was
described in angio-CT, as a superficial temporal artery
aneurysm
Using hydrophilic Progreat 2,5Fr (TERUMO)
selectively catheterized aneurysm, then it had been
closed using Azzur spiral 0.018’: 6 mm x 6 cm, 6
mm x 6 cm, 8 mm x 10 cm, 10 mm x 14 cm. After
procedure parietal angiography of right external carotid artery revealed unobstructed branches of right
occipital artery. Afterwards 4000 units of heparin
were injected. Course of operation was uncomplicated. Our patient had no recurrence of the mass
after coil occlusion at six months follow-up.
Fig. 2. Parietal angiography of right external carotid artery.
A. Aneurysm of branch of right occipital artery – 10.20 mm x 13.4 mm (angiography).
B. Endovascular coiling of aneurysm.
226
Discussion
Aneurysms of the distal branches of the external
carotid artery are seldom ascertain [1]. They are
in majority of cases the results of trauma (blunt,
penetrating or iatrogenic), but they can also reveal
as a spontaneous event or as an effect of infections
or autoimmune diseases [2]. Traumatic aneurysms
typically develop between two and six weeks after
blunt head trauma [3]. Aneurysms are considered
either false or true [2]. Pseudoaneurysms (false aneurysms) are more frequent in the scalp and don’t
involve all layers of the wall of artery [2,4]. However,
true aneurysms involve all three layers of arterial
wall (intima, media and adventitia) [2]. Aneurysms
of many branches of the external carotid artery have
been reported in the literature (superficial temporal,
facial, and terminal branches of the internal maxillary arteries) [5,6]. Before May 2013, our literature
review uncovered only 11 cases of aneurysm of
occipital artery (only four cases weren’t caused by
a trauma) [2]. Aneurysms of occipital arteries are
most common in adulthood (median age is 48 years
and 11 months old), with a male predominance
(63.6%) [2]. To expand previous knowledge about
aneurysms of occipital artery, we report the fifth case
of aneurysm of above-mentioned vessel not caused
by a trauma.
The occipital artery begins in posterior part of
the external carotid artery and ends in the posterior
portion of the scalp, where it cleaves into numerous branches and anastomoses with the posterior
auricular and superficial temporal arteries [1]. This
artery has three segments (from proximal to distal:
the digastric, sub-occipital and sub-galeal) [7].
To make a diagnosis for this disorder complete
history and physical examination are very useful
[3]. Symptoms of aneurysm of occipital artery are
nonspecific (tender, growing, painless and pulsating
mass located superficially in the course of the vessel)
[2,5,6]. Diagnosis can be delayed, especially if the
scalp mass is thrombosed and without pulsation
vascular lesion [2,5,6]. Our case shows that also
other symptoms can be present in this disease, like:
Otorynolaryngologia 2014, 13(4): 224-227
tinnitus and trismus. Differential diagnosis should
include lipomas, dermoid or epidermoid cysts, eosinophilic granulomas, hematomas, meningoceles,
abscesses, arteriovenous fistulas, encephaloceles,
lymphoid hyperplasias and sinus pericraniis [3,8,9].
If arterial aneurysm is clinically suspected, other
diagnostic tools will be substantial for correct diagnosis [2]. Ultrasound is one of a rapid technique
that allows identification of disorders of blood flow
within a palpable subcutaneous lesion by the use of
color Doppler techniques [7]. Computer tomography angiography (CTA) gives additionally significant
information about exact luminal morphology of vessel and relationship to adjacent bones and soft tissue
structures [2,9]. However, conventional angiography is considered to be a gold standard to evaluate
these lesions and to differ them from arteriovenous
malformations, which also evince as a pulsatile
subcutaneous masses [10]. Arteriography also offers
the option of immediate treatment by embolization
of the pseudoaneurysm sac or the affected artery
[3,11]. Recently, several authors report that, 3D-CTA
is the most eventual, non-invasive method for the
diagnosis of these lesions [3]. Our case shows that
sometimes Doppler ultrasonography and CTA are
insufficient to make appropriate diagnosis in spite
of numerous symptoms of the disease. The reason
of such difficulties can be caused by the fact that
the aneurysm was ascertained in a branch of occipital artery. In consequence other, better diagnostic
methods are necessary (like angiography or other
intra-procedural imaging) to diagnose arterial aneurysm and give proper specific treatment. Although
the natural history of the occipital artery aneurysm
is not well-known, indications in treatment of
mentioned disease include: reduction of the risk of
hemorrhage, a relief of pain and the alleviation of
disfigurements of the head [3]. Treatment methods
for occipital artery aneurysms are: simple resection
proximal ligation of the parent artery, trapping of
the aneurysm, percutaneous ultrasound guided
thrombosis of the lesion, and endovascular arterial
embolization or coil occlusion [1,3].
Górka M, Stapiński T, Wrońska J, et al. A rare case of non post-traumatic aneurysm of occipital artery
227
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