Severe Epistaxis Caused by Ruptured Aneurysm of the Internal Carotid Artery

Nontraumatic Internal Carotid Aneurysms in the Paranasal Sinuses Presenting with Epistaxis: A Case Report

Epistaxis due to rupture of a nontraumatic internal carotid artery (ICA) aneurysm in the paranasal sinus has rarely been reported. Here, we report a case of double ICA aneurysms located within both the sphenoid and ethmoid sinuses. A 78-year-old woman presented with recurrent massive epistaxis. Magnetic resonance angiogram (MRA) and cerebral angiogram showed two ICA aneurysms: one protruded into the sphenoid sinus and the other protruded into the ethmoid sinus. Intra-aneurysmal coil embolization was performed for both aneurysms. The patient recovered completely, and a follow-up MRA 3 years later showed no recurrence of the aneurysms. Intra-aneurysmal coil embolization is an option of treatment for an ICA aneurysm filling the paranasal sinus.

Mycotic aneurysm

Angioinvasive fungal infections of the cerebral vasculature often lead to significant morbidity and mortality. High clinical suspicion and early antifungal therapy could improve outcomes. We describe the fatal case of a patient with a rapidly enlarging cavernous carotid aneurysm due to angioinvasive fungus. This case highlights the challenges in diagnosis and management of this condition.

Management of carotid artery injuries: Louisiana State University Shreveport experience

BACKGROUND

Traumatic carotid artery injury is an infrequently encountered surgical entity. Carotid artery injuries in polytrauma patients can be easily missed in the absence of clinical findings and/or presence of confounding concurrent injuries.

METHODS

Between 1991 and 1998, 23 patients were diagnosed with various carotid artery injuries at the trauma center of Louisiana State University Health Sciences Center, Shreveport, Louisiana. Injuries were assessed by angiography and/or surgical exploration of the neck. Clinical presentations, radiologic features, management strategies, and neurologic outcomes were statistically analyzed and compared with the existing literature.

RESULTS

Twelve patients (52%) had penetrating carotid artery injuries, while 11 (48%) had blunt trauma. The diagnosis of carotid injury was significantly delayed in the group with blunt trauma as opposed to those with penetrating wounds. Surgical repair was performed in 6 (26%) patients; 2 (8%) underwent balloon occlusion, while ligation was conducted in 2 (8%) patients. Thirteen patients (57%) were treated conservatively with anticoagulants. Six patients (26%) died, while another 6 (26%) had permanent neurologic deficit. Mortality and morbidity was significantly higher in the group with penetrating injuries. A statistical analysis showed that multi-level carotid injury (p < 0.002) and increasing age (p < 0.001) had a significantly higher mortality.

CONCLUSIONS

Injury to carotid arteries results in significant mortality and morbidity. Our results indicate that penetrating carotid injury at more than one level carries higher mortality and morbidity rates than blunt injury. Furthermore, early identification of the injured segment may favorably influence the outcome for such patients.

Epistaxis due to traumatic internal carotid artery aneurysm

Epistaxis due to internal carotid artery (ICA) trauma is uncommon, and that due to aneurysm of the artery is rarer still. Most cases result in fatality due to severe, uncontrolled blood loss. The ICA is vulnerable to oropharyngeal trauma as it ascends beside the lateral pharyngeal wall. We describe a case of an 11-month-old girl who sustained oropharyngeal wall trauma from the handle of a wooden spoon. After a characteristic latent period of several days, upper airway obstruction occurred due to a right parapharyngeal mass, which extended inferiorly to the level of the larynx. Angiography confirmed a large dissecting ICA aneurysm. This was treated successfully by radiological coil occlusion.

Cavernous carotid aneurysms rarely cause subarachnoid hemorrhage or major neurologic morbidity

GOAL

To determine whether aneurysms of the cavernous internal carotid artery (CCA) cause major neurologic morbidity or death.

METHODS

Retrospective analysis of all patients with a spontaneous CCA evaluated by a referral multidisciplinary neurovascular service from 1981 to 2000. All patients had complete clinical neuro-ophthalmologic and neurologic examinations and magnetic resonance imaging (MRI) or computed tomography (CT) with angiographic diagnostic confirmation. Follow-up evaluations were performed by our service in the majority of patients, and the remaining patients' subsequent examinations were obtained from the referring physicians.

RESULTS

One hundred seventy-four patients (mean age 60.7 years, median age 63 years, 161 women, 13 men) had 193 CCA. All 19 patients with bilateral CCAs were female. Twenty-eight patients had 1 or more subarachnoid aneurysms. The presentation included 156 aneurysms with pain or cranial neuropathy or both, 13 with a carotid cavernous fistula (CCF), and 24 asymptomatic CCAs. Two patients, both with a coagulopathy, had a cerebral infarct ipsilateral to the CCA, 1 at presentation and the other 2 years after partial third nerve palsy. One patient had a subarachnoid hemorrhage (SAH) 2.3 years after presentation, and no patient had arterial epistaxis or a CCA-related death. Excluding the 15 patients (16 aneurysms) who had no follow-up or died from SAH due to a subarachnoid aneurysm, 177 aneurysms were followed up for a mean duration of 3.10 years (SD = 3.6). One hundred six never-treated aneurysms were followed for 4.5 years (SD = 3.80, range 0.1-17), and 71 ultimately treated aneurysms were followed for 1.56 years (SD = 2.69, range 0.1-15). The overall rate for SAH was 0.19% and for a CCA-associated cerebral infarct was 0.37% per patient year. There were no correlations with cerebral infarct, SAH, or CCF and diabetes mellitus, hypertension, gender, age, cranial neuropathy, or size of the aneurysm, except for the largest diameter of the aneurysm and CCF (r = 0.17, P = .018). However, all of the patients with cerebral infarct or SAH and 12 of the 13 CCF had an aneurysm diameter > or = 1 cm.

CONCLUSIONS

CCA is a disorder with strong female gender bias that uncommonly causes major neurologic complications. These data suggest that CCA should not be included in analyses that determine the risk of severe neurologic morbidity, hemorrhage, or death due to intracranial aneurysms.

"Early" apoplexy due to traumatic intracranial aneurysm--case report

A 76-year-old man presented with a traumatic aneurysm of the left internal carotid artery which caused repeated subarachnoid hemorrhages within 20 hours of a fall from a height. Early computed tomography (CT) detected no brain abnormalities, but repeat CT found subarachnoid hemorrhage. Internal carotid angiography detected a pseudoaneurysm, which was not treated because of his poor clinical condition. He died of multiple organ failure. Early detection of a traumatic intracranial aneurysm is important for the prevention of aneurysmal rupture, or "delayed" apoplexy. Review of 171 cases with traumatic aneurysms from the literature found that false negative angiography occurred only in three cases on post-trauma day 7 and thereafter. Early diagnostic angiography within a week of the initial trauma is indicated if traumatic aneurysm is suspected to detect early signs of irregularity, spasm, and narrowing of the arterial wall. Repeat angiography is indicated if aneurysmal formation is still highly suspected in spite of negative initial angiography.

Recurrent massive epistaxis due to traumatic intracavernous internal carotid artery aneurysm

Traumatic internal carotid artery aneurysm presenting with epistaxis is rare. Epistaxis often occurs after a delay of weeks to months following head injury. The present case had bouts of recurrent massive epistaxis nearly four months after head injury. Diagnosis was made after carotid angiography. Epistaxis ceased after ipsilateral carotid ligation.

Traumatic intracranial aneurysms in childhood and adolescence. Case reports and review of the literature

We report four pediatric traumatic intracranial aneurysms occurring before the age of 10 years. Two of these aneurysms were the result of closed head injury. The remaining two were iatrogenic aneurysms which occurred in unusual circumstances. These four children represent 33% of the pediatric intracranial aneurysms seen at the Children's Hospital of Eastern Ontario from 1974 to 1992. Diagnosis of traumatic intracranial aneurysms requires a high index of suspicion: any head-injured or postoperative child who experiences delayed neurologic deterioration, or who fails to improve as expected following treatment, should promptly undergo diagnostic intracranial imaging. Documented subarachnoid hemorrhage, intracerebral or intraventricular hemorrhage, or subdural haematoma in this clinical setting should be further investigated by cerebral angiography to exclude a traumatic aneurysm or other vascular lesion. Traumatic aneurysms typically arise at the skull base or from distal anterior or middle cerebral arteries or branches consequent to direct mural injury or to acceleration-induced shear. Reported traumatic aneurysms account for 14%-39% of all pediatric aneurysms. Iatrogenic aneurysms also occur with unexpected frequency during childhood and adolescence. Pediatric traumatic cerebral aneurysms may present early or late. Most present early with intracranial hemorrhage. Late presentation occurs infrequently, typically as an aneurysmal mass. Once diagnosed, these aneurysms should be promptly treated by craniotomy employing routine microsurgical techniques, or in some cases, by endovascular detachable balloon techniques. Delay in operative treatment entails significant risks of repeated hemorrhage and death. Outcome in these children is primarily determined by the extent of traumatic cerebral injury and the preoperative clinical status. The latter directly depends upon diagnosis of the aneurysm prior to either initial or repeated hemorrhage.

Massive epistaxis following sphenoid sinus exploration

Internal carotid artery trauma is a rare but potentially disastrous complication of surgery to the sphenoid sinus and pituitary gland. Emergency and elective procedures to establish haemostasis are discussed.

The benign course of cavernous carotid artery aneurysms

Recently, the benign nature of aneurysms of the cavernous carotid artery has been questioned. In a review of cases evaluated from 1980 to 1990 with this developmental aneurysm, the authors found 70 patients with 79 cavernous carotid artery aneurysms. As expected, the great majority (59 patients) had ophthalmoplegia as the initial problem. Retro-orbital pain (three cases) and a carotid-cavernous fistula (five cases) were infrequently the sole manifestation. Mirror-image asymptomatic aneurysms were found in nine patients and asymptomatic cavernous aneurysms were found in three additional patients. Thirty-four patients not surgically treated were followed for a mean of 2.8 years, and 36 surgical patients were followed for a mean of 4.1 years prior to treatment. Of the 79 aneurysms, one (1.3%) ruptured into the subarachnoid space during this period. Other than optic neuropathy or cranial neuropathy, no patient had a permanent neurological deficit; the 12 asymptomatic aneurysms remained asymptomatic. It is concluded that an aneurysm of the cavernous carotid artery is rarely associated with life-threatening complications, and treatment should be considered principally for patients with intolerable pain or problems related to vision.

Intracavernous carotid artery aneurysm presenting as recurrent epistaxis

Massive epistaxis from a leaking intracavernous carotid artery aneurysm is a rare occurrence. Such an unusual case is presented with appropriate imaging and a successful treatment program.

Subarachnoid hemorrhage possibly caused by a saccular carotid artery aneurysm within the cavernous sinus. Case report

Aneurysms arising from the intracavernous portion of the internal carotid artery very rarely rupture. A patient is presented in whom rupture of an aneurysm wholly within the cavernous sinus caused a subarachnoid hemorrhage. The aneurysm was successfully clipped via a direct surgical approach. The possible mechanism by which subarachnoid hemorrhage occurred is briefly discussed.

Traumatic giant aneurysms of the intracranial carotid artery presenting long after head injury

Three patients presented with giant aneurysms of the intracranial internal carotid artery that became symptomatic with expanding mass effects 4-10 years after severe head trauma accompanied by skull base injuries at the site of aneurysm formation. These aneurysms are therefore considered to be late manifestations of traumatic vessel disruption. Posttraumatic aneurysm growth was documented in one case of a supraclinoidal aneurysm. One intracavernous aneurysm was combined with a traumatic carotid-cavernous sinus fistula. Although the origin of intracranial aneurysms is usually considered to be traumatic only within a period of weeks or months after head injuries, giant aneurysms of the intracranial internal carotid may represent late complications of trauma in a number of cases.

Internal carotid artery epistaxis

Epistaxis from the internal carotid artery (ICA) or bleeding from the ICA at the skull base is a rare, frightening, and difficult management problem. We present five cases, with a variety of causes--in all of which the patients survived massive hemorrhage--and suggest a protocol for management of the condition.

Traumatic internal carotid artery aneurysm with rupture into the sphenoid sinus

A case of cavernous-internal carotid artery aneurysm with delayed rupture into the sphenoid sinus is presented, and the literature reviewed. We stress important diagnostic features such as epistaxis, which may require emergent use of epistaxis balloon catheters. Cervical carotid ligation and intracranial clipping of the internal carotid artery proximal to the ophthalmic artery controlled the bleeding and resulted in no neurologic sequelae.

Spontaneous intracerebral hematoma in carotid-cavernous fistula. Report of three cases

Spontaneous intracerebral hematoma associated with carotid-cavernous fistula is rare. Three new cases are presented. In each, the hemorrhage originated in the vicinity of localized intracranial venous engorgement, as demonstrated by cerebral angiography. Rupture of one or several of the distended venous channels from increased back-flow is postulated as the etiology of the intraparenchymal hematomas.

Giant traumatic false aneurysm of the internal carotid artery associated with a carotid-cavernous fistula. Case report

A case of giant traumatic false aneurysm of the intracranial internal carotid artery (ICA) with a concomitant carotid-cavernous fistula is reported. The fistula and the aneurysm persisted after ipsilateral cervical ICA ligation was performed elsewhere. Successful obliteration of the aneurysm and the fistula, with preservation of cross filling of the ipsilateral middle cerebral artery system, was accomplished by ligation of the intracranial ICA proximal to the origin of the posterior communicating artery with a 7-0 prolene suture, followed by transaneurysmal packing of the fistula.

Balloon catheter occlusion for cavernous carotid artery injury during transsphenoidal hypophysectomy. Case report

During transsphenoidal hypophysectomy for pituitary ablation in a patient with disseminated breast cancer, brisk arterial hemorrhage occurred during separation of adhesions between the pituitary gland and the wall of the cavernous sinus. Hemorrhage was controlled by placement of a Prolo balloon catheter into the internal carotid artery (ICA) that occluded the site of hemorrhage. The patient experienced no neurological sequelae. The cervical ICA was easily exposed for insertion of this double-lumen catheter. With the image intensifier already in position, injection of contrast material through the arteriography lumen allowed precise localization of the site of injury and directed positioning of the balloon for control of the hemorrhage.

Fatal epistaxis from an aneurysm of the intracranial internal carotid artery

An instance of fatal epistaxis is reported in a patient with an unsuspected aneurysm of the infraclinoid portion of the internal carotid artery. There was no known history of trauma. The aneurysm was subsequently detected on an old X-ray film. Epistaxis from an aneurysm at this site is nearly always preceded by significant head trauma and is associated with cranial nerve palsies, a syndrome with a high mortality. Epistaxis from rupture of a non-traumatic aneurysm is very rare.

Intracavernous aneurysm of the carotid artery following transsphenoidal surgery. Case report

An intracavernous aneurysm of the left internal carotid artery arose following transsphenoidal surgery in this patient. The pathogenic, clinical, and therapeutic aspects of the case are discussed. Only four other iatrogenic intracavernous carotid aneurysms have been reported previously.

False aneurysm of the cavernous carotid artery and progressive external ophthalmoplegia after transsphenoidal hypophysectomy. Case report

A case is reported in which a large false aneurysm and small associated fistula formed in the cavernous carotid artery as the result of laceration at the time of transsphenoidal surgery. The clinical syndrome associated with the enlarging mass and the surgical management of the lesion itself are described. The value of the midline approach to the sella is stressed, along with anatomical variants of the carotid artery.

Traumatic aneurysm of the internal carotid artery and epistaxis. (Review of literature and report of a case)

A review of 108 years of world literature revealed 69 cases fulfilling the picture of a clinical syndrome of head injury, a latent period followed by epistaxis and cranial nerve lesions. A similar case has been added which is the fourth case to be reported to be due to a bullet injury. The applied anatomy of the intracranial internal carotid artery (ICA) and the aetiology, clinical syndrome, pathology, diagnosis, prognosis and management of ICA aneurysms have been briefly discussed.

Neurovascular relationships of the sphenoid sinus. A microsurgical study

✓ The increasing use of the transsphenoidal approach to sellar tumors has created a need for more detailed information about the neurovascular relationships of the sphenoid sinus. To better define this anatomy, 25 sphenoid sinuses were examined in cadavers, with attention to the neural and vascular structures in the lateral wall of the sinus. Three structures produced prominent bulges into the lateral wall of the sinus; they were 1) the optic nerves, 2) the carotid arteries, and 3) the maxillary branches of the trigeminal nerve. Over half of these structures had a bone thickness of less than 0.5 mm separating them from the sphenoid sinus, and in a few cases, they were separated by only sinus mucosa and dura.

1) The optic canals protruded into the superolateral part of the sphenoid sinus in all except one side of one specimen. In 4% of the optic nerves, only the optic sheath and sinus mucosa separated the nerves from the sinus, and in 78%, less than a 0.5-mm thickness of bone separated them. 2) The carotid arteries produced a prominent bulge into the sphenoid sinus in all but one side of one specimen. In 8% of the carotid arteries there were areas where no bone separated the artery and the sinus. 3) The maxillary branches of trigeminal nerves bulged into the inferolateral part of the sphenoid sinus in all except one side of two specimens. One side of one specimen had no bone, and 70% had less than a 0.5-mm thickness of bone separating the nerve from the sinus. The importance of these findings in transsphenoidal surgery is reviewed.

Aneurysms of the petrous or cavernous portions of the internal carotid artery associated with nonpenetrating head trauma

✓ Four instances of aneurysms of the petrous or cavernous portions of the internal carotid artery following nonpenetrating head injury are reported and discussed.