Flow-diverter stenting in post-traumatic pseudoaneurysm of cavernous internal carotid artery with epistaxis

Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience

Background and objective

To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach.

Methods

We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative “sandwich technique” combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed.

Results

No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus.

Conclusions

Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.

Treatment of Intracranial Pseudoaneurysms With a Novel Covered Stent: A Series of 19 Patients With Midterm Follow-Up

Background: The optimal treatment for intracranial pseudoaneurysm is unclear. This study aims to analyze the outcome of treating intracranial pseudoaneurysm with a novel covered stent.

Materials and Methods: The institutional imaging and clinical databases were retrospectively reviewed for patients with intracranial pseudoaneurysms treated with Willis covered stent from January 2017 to December 2019. The clinical presentations, etiology, intraoperative complications, and immediate and follow-up outcomes were analyzed.

Results: A total of 19 patients with 20 pseudoaneurysms were enrolled for analysis. Seventeen patients presented with vision loss and two with epistaxis. Nineteen Willis covered stents were used with one for each patient without technical failure. Intraoperative thrombosis was encountered in one patient (5.3%), which was recanalized by tirofiban. During clinical follow-up, no further epistaxis occurred, and visual acuity improved in three (17.6%) patients. Endoleak occurred in seven (36.8%) patients after the initial balloon inflation and persisted in one (5.3%) patient after balloon re-inflation. This endoleak disappeared at 8 month follow-up. Finally, during angiographic follow-up (median 13 months), parent artery occlusion and in-stent stenosis occurred in one (5.3%) patient. No stent-related ischemic event was encountered.

Conclusions: The Willis covered stent is feasible, safe, and efficient in treating intracranial pseudoaneurysms.

Endovascular treatment of traumatic carotid pseudoaneurysm with Tubridge flow diverter: A case report

Traumatic pseudoaneurysm is a rare lesion with a high risk of rupture, and represents one of the most difficult lesions to treat, either surgically or endovascularly. Herein, we describe the case of a 32-year-old man with a traumatic pseudoaneurysm of the internal carotid artery, which was treated by overlapped flow diverters (Tubridge). The patient recovered well, and the follow-up angiography at four months showed complete occlusion of the pseudoaneurysm and patency of the internal carotid artery and the ophthalmic artery.

Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery

BACKGROUND

Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries.

CASE REPORT

We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction.

CONCLUSIONS

Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.

Equine pericardium-covered stenting in post-traumatic pseudoaneurysm of cavernous internal carotid artery

We report a case of traumatic intracranial carotid artery pseudoaneurysm treated with an equine pericardium-covered stent. The patient was admitted to the Emergency Department after sustaining severe polytrauma in a motor vehicle accident. A cavernous carotid pseudoaneurysm was detected after an episode of massive epistaxis that required emergent nasal packing. Treatment with parent vessel sacrifice was ruled out after an unfavourable balloon test occlusion. We opted for an equine pericardium-covered stent as a means to immediately seal the wall defect in the setting of massive bleeding secondary to an unstable lesion. We describe the potential benefits and drawbacks of these prostheses and the technical difficulties encountered in this particular case. To our best knowledge, this is the first published case report on a post-traumatic intracranial internal carotid artery pseudoaneurysm successfully treated with an equine pericardium-covered stent.

Late-Onset Massive Epistaxis due to a Ruptured Traumatic Internal Carotid Artery Aneurysm: A Case Report

A traumatic internal carotid artery (ICA) aneurysm is rare and difficult to treat. Trapping of ICA is commonly performed owing to the difficulty of directly approaching ICA aneurysms. Recently, coiling the aneurysm itself was recommended if possible. However, it is controversial which of methods are best to completely treat aneurysm. We present the case of a 74-year-old man, who had experienced a head injury 8 years previously, with recurrent severe epistaxis. An ICA aneurysm was detected on computed tomography. The trapping and bypass was planned. However, sudden epistaxis occurred, we performed trapping to stop the bleeding and save his life. After the operation, no right ICA or aneurysm was detected. However, severe epistaxis recurred two months after the operation. In the second operation, a ligation of the common -/- external carotid artery and a severance of an ICA portion between the ophthalmic artery and the aneurysm were insufficient to stop the bleeding. This case indicates ICA trapping, even if a trapping portion is below an ophthalmic artery, is insufficient to treat an ICA aneurysm. ICA aneurysms should be suspected when a patient present with recurrent -/- massive epistaxis, who has a head injury history, even if it is far past.

Traumatic Anterior Cerebral Artery Pseudoaneurysmal Epistaxis

BACKGROUND

Pseudoaneurysmal epistaxis is a rare but emergent condition. We report a case of traumatic anterior cerebral artery pseudoaneurysmal epistaxis and review the published literature.

CASE DESCRIPTION

A 49-year-old man sustained severe head trauma. He was diagnosed with multiple skull bone fractures, left subdural hematoma, subarachnoid hemorrhage, pneumocephalus, and right frontal hematoma. Subdural hematoma evacuation was done at a local hospital. In the following months, he experienced repeated epistaxis that required nasal packing to stop the bleeding. Digital subtraction angiography showed an anterior cerebral artery pseudoaneurysm protruding into the posterior ethmoid sinus. Embolization of the aneurysm was performed with microcoils, and the parent artery was occluded by thrombosis. The patient presented 1 month later with another epistaxis episode. Digital subtraction angiography showed recanalization of the parent artery and recurrence of the aneurysm. The parent artery was occluded for the second time with coils and Onyx embolic agent.

CONCLUSIONS

Pseudoaneurysmal epistaxis is rare, and this is the first report of an anterior cerebral artery pseudoaneurysm that manifested with epistaxis. Endovascular intervention has become the first choice of treatment for this disease. The high recurrence rate is the main disadvantage of endovascular intervention. Aneurysm trapping with bypass surgery is another treatment option.

Endovascular Treatment of Extracranial Internal Carotid Pseudoaneurysm: Description of Three Cases

The aim of this study is to explore the possibility of endovascular treatment of internal carotid artery pseudoaneurysm (PSA). These lesions are difficult to treat with a surgical approach, especially if they are located extracranially and close to the skull base. Endovascular stent placement in symptomatic and unstable extracranial internal carotid PSA was found to be safe and effective. Depending on hemodynamic aspects, complete local exclusion of aneurysmal formation is achieved in few months. We present three patients with carotid dissection and PSA formation that have been successfully treated by stent placement.