Delayed Presentation of an Extracranial Internal Carotid Artery Pseudoaneurysm and Massive Epistaxis Secondary to a Nasal Foreign Body: Case Report and Review of the Literature

Nasopharyngeal Migration of Coils Following Embolization of a Traumatic Pseudoaneurysm of the Internal Carotid Artery: A Case Report

Post-traumatic pseudoaneurysms of the internal carotid are a rare but potentially fatal cause of epistaxis; they are associated with fractures of the base of the skull with involvement of the carotid canal. Endovascular management is the preferred therapeutic strategy, with optimal long-term results and low complication rates. Complications may include thromboembolic events, infarction of perforating arteries, and rupture of the pseudoaneurysm. We present a case of a 28-year-old male with a post-traumatic pseudoaneurysm of the internal carotid who was managed with endovascular therapy. A late complication was the extrusion of the embolization material into the nasal cavity and nasopharynx, which was safely and effectively treated through endovascular and endoscopic approaches.

Etiology and treatment patterns of ruptured extracranial carotid artery aneurysm

OBJECTIVE

Rupture of an extracranial carotid artery aneurysm (ECAA) is a very rare and life-threatening condition. To obtain a comprehensive view of previous and current management of ruptured ECAAs (rECAAs), we analyzed all cases reported since 1940 and two of our own cases.

METHODS

We performed a comprehensive literature review of reports from the MEDLINE database on rECAAs and included two patients treated in our department.

RESULTS

A total 58 reports of 74 rECAAs in 74 patients were analyzed. Their mean age was 50 years, and the male/female ratio was 2.2:1. Infection was the most common reported etiology (19 of 74; 26%), followed by connective tissue disorder (13 of 74; 18%), atherosclerosis (9 of 74; 12%), and previous trauma (5 of 74; 7%). For 28 patients (38%), information on the etiology was not available. Of the 74 patients, 24 (32%) had undergone reconstructive surgery, 10 (14%) had undergone endovascular treatment, 17 (23%) had undergone ligation, 2 (3%) had been treated conservatively, and 1 (1%) had died before receiving definite treatment. For 20 patients (27%), information on the treatment received was not available. The complications after reconstruction included carotid blowout (3 of 24 patients; 13%) and cranial nerve deficit (3 of 24 patients; 13%). Two patients (8%) had died of unrelated ECAA causes during long-term follow-up, and one patient (4%) had died of an ECAA-related cause within 30 days. After an endovascular approach, 1 of the 10 patients had developed a cranial nerve deficit. After ligation, five patients (29%) had experienced stroke, three of which were fatal. One conservatively treated patient had experienced no complications and one had died of an ECAA-related cause.

CONCLUSIONS

The most common reported etiology for rECAA was infection. Reconstructive surgery was the most common approach and was safer than ligation, which carried a high risk of stroke. Endovascular treatment showed promising results, especially for distally located aneurysms; however, the number of patients has remained low.

Εndovascular Repair of Extracranial Carotid Artery Aneurysms: A Systematic Review

OBJECTIVE

Both true and false extracranial carotid artery aneurysms (ECAA) are a potential source of morbidity and mortality. While ECAA have historically been treated surgically, endovascular reconstruction with stenting is an emerging treatment option. The aim of our study was to report clinical/radiologic outcomes following endovascular repair of ECAAs.

METHODS

A comprehensive systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

A total of 68 case reports and case series, comprising 162 patients, were included. Most patients presented with at least one symptom or sign related to the ECAA (89.5%; N = 145/162). In 42.6% (N = 69/162) and 46.3% (N = 75/162) of the cases polytetrafluoroethylene covered and uncovered stents were deployed respectively. Immediate post-procedural imaging demonstrated complete aneurysm exclusion in 86.4% (N = 140/162) of the cases and minimal filling of the aneurysm sack in 10.5% (N = 17/162) of all cases. Perioperative adverse event rates were 3.1% for stroke, 1.2% for transient ischemic attack (TIA) and 4.3% for mortality. During a mean follow-up of 21.8months, there were additionally observed one stroke, two TIAs and three deaths. Overall 88.6 % of the patients (N = 117/132) remained asymptomatic, partially recovered or at least did not suffer from new neurologic deficits during follow up, with no signs of stenosis or occlusion of the carotid artery.

CONCLUSIONS

Endovascular stenting for the treatment of ECAAs is feasible with acceptable short- and long-term clinical and radiologic outcomes. Prospective real-world studies are needed to further validate the safety and the long-term patency of endovascular repair.