Acute intraparenchymal hemorrhage caused by rupture of a traumatic pseudoaneurysm of the middlemeningeal artery - Letters to the Editor - Clinician recommendations

Sep 28, 2026

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Letter to the editor analyzing a reported case of acute intraparenchymal hemorrhage from rupture of a traumatic middle meningeal artery (MMA) pseudoaneurysm. The author comments on usefulness of CT angiography for diagnosis and requests clearer visualization of pseudoaneurysms in figures. Key discussion addresses rare occurrence of IPH versus typically dominant epidural hematoma, possible mechanisms related to dural surface location, and the need for more detailed description to clarify pathophysiology. Additional recommendations include hematoxylin and eosin staining to highlight tears.

LanguageEnglish

CategoryHealthcare

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Pages2

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Letters to the Editor

Imaging recommendations for CT angiography

Mechanisms of IPH versus EDH and dural location

Histopathology and staining suggestions

Journal of Cerebrovascular Endovascular Neurosurgery and Journal of Cerebrovascular and Endovascular Neurosurgery pISSN 2234-8565, eISSN 2287-3139, [https://doi.org/10.7461/jcen.2025.E2025.04.001](https://doi.org/10.7461/jcen.2025.E2025.04.001) Letters to the Editor Acute intraparenchymal hemorrhage caused by rupture of a traumatic pseudoaneurysm of the middlemeningeal artery Myoung Soo Kim Division of Neurosurgery, Seoul Regional Trauma Center, National Medical Center, Seoul, Republic of Korea J Cerebrovasc Endovasc Neurosurg. 2025 December;27(4):385-386 Received: 7 April 2025 Revised: 6 June 2025 Accepted: 28 July 2025 Correspondence to Myoung Soo Kim Division of Neurosurgery, Seoul Regional Trauma Center, National Medical Center, Euljiro 245, Jung-gu, Seoul 04564, Republic of Korea Tel +82-2-2260-7180 Fax +82-2-2262-4876 E-mail [hanibalkms@hanmail.net](hanibalkms@hanmail.net) ORCID [https://orcid.org/0000-0001-9556-9846](https://orcid.org/0000-0001-9556-9846) This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ([http://creativecommons.org/licenses/](http://creativecommons.org/licenses/)[ ](http://creativecommons.org/licenses/)[by-nc/4.0/](by-nc/4.0/)) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. TO THE EDITOR I read the case report by Mohammed et al. 1) regarding a pseudoaneurysm of the middle meningeal artery (MMA) . In Table 1, the authors review the cases of 10 patients with acute intraparenchymal hemorrhage (IPH) because of MMA pseudoaneurysm. I also experienced a similar case.2) In the most recent case report, computed tomographic (CT) angiography was useful for the diagnosis of pseudoaneurysm. However, in Fig. 1B, I could not find a definite pseudoaneurysm, as this figure shows the source image without reconstructive CT angiography. I recommend presenting CT angiography to show MMA pseudoaneurysms. Such images can provide critical information for clinicians. In most cases of acute traumatic pseudoaneurysm in the MMA, epidural hematoma (EDH) is the dominant presentation. Acute IPH because of pseudoaneurysm in the MMA is very rare. Moon et al.2) reported that traumatic pseudoaneurysm in the MMA resulted in EDH and IPH connected via a dural tear. Moreover, the pseudoaneurysm was located on the outer surface of the dura mater. Rupture of the MMA pseudoaneurysm resulted in EDH, and additional bleeding resulted in IPH via the dural tear, although cerebral contusion was not found in the operative field. In the case reported by Mohammed et al.,1) I wondered about the exact location of the pseudoaneurysm in the dura mater (e.g., outer or inner surface) . I could not find EDH in Fig. 1A; therefore, it is possible that another mechanism resulted in IPH in this case. One possibility is the separate development of the pseudoaneurysm and the IPH, which might have resulted from cerebral contusion after the trauma. To identify the exact mechanism ofIPH, I recommend a more detailed description. Lim et al.3) reported a case similar to that reported by Mohammed et al.,1) in which the patient’s skull appeared unremarkable. On the inner surface of the intact dura, Copyright © 2025 by KSCVS and KoNES [www.the-jcen.org](www.the-jcen.org) 385 Pseudoaneurysm of the middle meningeal artery there was an irregularly shaped aneurysm arising from the MMA and active bleeding from the injured right MMA. In this case, the pseudoaneurysm located on the inner surface of the dura mater might lead to the development ofIPH. Mohammed et al. 1) reported that histopathology of the pseudoaneurysm revealed the presence of an aneurysmal sac with a tear lined by a fibrin clot. Pseudoaneurysms typically lack a well-defined aneurysmal sac. I recommend presenting hematoxylin and eosin staining of the aneurysmal sac and highlighting the presence of the tea

FAQs

Why does the author recommend CT angiography in the case figures?

The author notes that CT angiography helps identify the pseudoaneurysm and recommends presenting it clearly because the source image without reconstructive CT angiography did not show a definite pseudoaneurysm.

How does the letter explain the rarity of acute intraparenchymal hemorrhage in MMA pseudoaneurysm?

The author states that EDH is usually the dominant presentation, while IPH from MMA pseudoaneurysm rupture is very rare. They discuss mechanisms involving dural tears and how IPH can connect to or arise independently from EDH.

What additional histopathology details does the author suggest?

The author recommends presenting hematoxylin and eosin staining of the aneurysmal sac and highlighting the tear, emphasizing that pseudoaneurysms typically lack a well-defined aneurysmal sac.

Sep 28, 2026

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