Delayed Intracerebral Hemorrhage After Pseudoaneurysm of Middle Meningeal Artery Rupture: Case Report, Literature Review, and Forensic Issues

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. •Temporal rim fracture and small hematoma near the rim are the 2 risk factors, together associated to pseudoaneurysm formation.•In presence of the 2 risk factors, CTA is strongly recommended in the first 7-10 days after head trauma.•CTA is better performed electively than in an emergency so that it is easier to detect PMMA.