Endovascular treatment of radiation-induced petrous internal carotid artery aneurysm presenting with acute haemorrhage. A report of two cases

The prognosis and treatment effectiveness of de novo aneurysm formation after radiation therapy for brain tumor

Radiation therapy is a well-established, minimally invasive method of treating brain tumors. In recent years, the number of post-radiotherapy patients has increased, and delayed side effects are evident. De novo aneurysm formation after radiation often manifests as fatal subarachnoid hemorrhage (SAH), resulting in severe clinical outcomes. Nevertheless, the prognosis and therapeutic efficacy of radiation-induced aneurysms (RIAs) remain unclear. Using the PubMed database from 1980 to 2021, we screened 45 articles (53 individual cases) on RIAs; approximately 70% of RIAs were diagnosed after rupture. Of 38 ruptured RIAs, 12 (31.6%) had modified Rankin scale (mRS) 5-6. On the other hand, all unruptured RIAs (15 cases) recovered without neurological deficits (p = 0.012). Ten of the 39 ruptured RIAs were treated surgically, and 22 were treated endovascularly. There was no significant difference in mRS between treatment modalities (p = 0.393), but conservative therapy was significantly related to unfavorable outcomes (p = 0.025). To improve clinical outcomes, RIAs need to be diagnosed before rupture. Surgeons should be aware of de novo aneurysm formation in patients long after radiation therapy.

Carotid Blowout Syndrome in the Emergency Department: A Case Report and Review of the Literature

BACKGROUND

Carotid blowout syndrome (CBS) is an infrequent but dangerous oncologic emergency that must be recognized due to a mortality rate that approaches 40% and neurologic morbidity that approaches 60%. Patients present with a variety of symptoms ranging from asymptomatic to frank hemorrhage, and appropriate recognition and management may improve their outcomes.

CASE REPORT

A man in his late 60s with squamous cell carcinoma of the oropharynx presented to the emergency department (ED) with hemoptysis and several episodes of post-tussive emesis with large clots. He had been cancer free for multiple years after treatment with chemotherapy and radiation to the neck. Evaluation revealed a necrotic tumor on the posterior pharynx on bedside laryngoscopy and an external carotid pseudoaneurysm that was stented by interventional radiology. The patient experienced recurrent hemorrhage several months later and opted for palliative measures and expired of massive hemorrhage in the ED on a subsequent visit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CBS can be fatal, and early suspicion and recognition are key to ensure that a threatened or impending carotid blowout are appropriately managed. Once carotid blowout is suspected, early resuscitation and consultation with interventional radiology and vascular surgery is warranted.

Internal carotid artery blister aneurysm rupture: a unifying diagnosis for massive epistaxis and unilateral embolic strokes

Concurrent epistaxis, embolic stroke and a ruptured internal carotid artery are rare but life-threatening delayed complications of cured nasopharyngeal squamous cell carcinoma. A timely diagnosis and effective management can be problematic. We report a case that highlights the unique diagnostic features of this presentation and contemporary endovascular treatment options available.

A case of catastrophic epistaxis from the internal carotid artery due to multiple surgeries and irradiations for pituitary tumor: Rescued utilizing high-flow bypass and simultaneous skull base reconstruction

Revascularization for internal carotid artery rupture should be considered immediately under the situation where endovascular treatment is not indicated. Revascularization can prevent the risk of hemorrhage during skull base reconstruction.

Endovascular Management of Intractable Nasopharyngeal Hemorrhage in Patients Irradiated for Nasopharyngeal Carcinoma: A Twelve-Year Experience

Purpose

To evaluate the efficacy of endovascular treatment of intractable nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and report the relevant endovascular therapeutic experience.

Patients and Methods

Records of patients who underwent endovascular treatment for intractable nasopharyngeal hemorrhage after irradiation for NPC from January 2007 to December 2019 were reviewed. The demographics, endovascular therapeutic details, and clinical outcomes were analyzed.

Results

Twenty-four consecutive patients were included in this study. Nineteen patients underwent embolization of the bilateral internal maxillary arteries; one patient underwent embolization of the right internal maxillary artery and the left external carotid artery; one patient underwent embolization of the left internal maxillary artery and the right internal carotid artery, and the other three patients underwent embolization of the unilateral internal carotid artery. During a mean follow-up of 600.9 days (range, 2–1658 days), twenty patients showed no recurrence of bleeding; one patient died of hemorrhagic shock; one patient had recurrent bleeding, and angiography revealed a pseudoaneurysm in the right internal carotid artery, which was then embolized with spring coil after a 30-min occlusion test. Two patients had recurrent bleeding on 2.5 months and 29.9 months respectively after the endovascular treatment, and angiography showed hypervascularity supplied by the bilateral internal maxillary arteries and then was embolized with polyvinyl alcohol particles. The three patients who received re-interventions showed no re-bleeding until the last follow-up.

Conclusion

Pseudoaneurysm and hypervascularity are the main angiographic characteristics of patients with intractable nasopharyngeal hemorrhage after radiotherapy for NPC, and endovascular treatment provides a safe and effective management approach.

Giant intracranial aneurysm following radiation therapy: literature review with a novel case discussion

BACKGROUND

The aim of this paper is to report the results of our review of the literature of published cases of intracranial aneurysms appearing after radiotherapy, and to present our case to add it to the current literature, in order to discuss the role of inflammation.

METHODS

We searched the PubMed database using combinations of the following MeSH terms: intracranial aneurysm, radiosurgery, radiotherapy, inflammatory changes in aneurysmal walls from 1967 to 2019.

RESULTS

51 studies, for a total cohort of 60 patients, are described. The median latency between the radiation treatment and the diagnosis was 9,83 years, ranging from a minimum of 0,33 to a maximum of 33. The modality of rays' administration was variable, and the dosage ranged from a minimum of 12 grays to a maximum of 177,2 grays. The anterior circulation appeared to be more frequently involved, and the most compromised vessel was the internal carotid artery. Radiation-induced vascular diseases have already been described in literature as well as RT-induced cellular and structural changes such as necrosis, macrophage or mononuclear cell infiltration, and several data support the role of inflammation in the development and remodelling of intracranial aneurysms, that, on one hand, favours them and, on the other, is necessary to their healing after endovascular treatment.

CONCLUSIONS

Our team suggested a new insight in the management of these vascular lesions, which corresponds to a lower threshold when deciding whether or not to treat, and a longer and stricter follow-up.

Carotid blowout syndrome after reirradiation for head and neck malignancies: a comprehensive systematic review for a pragmatic multidisciplinary approach

AIM

To provide a literature review on risk factors and strategies to prevent acute carotid blowout (CBO) syndrome in patients who underwent reirradiation (reRT) for recurrent head and neck (HN) malignancies.

PATIENTS AND METHODS

Inclusion criteria were: 1) CBO following reRT in the HN region, 2) description on patient-, tumor- or treatment-related risk factors, 3) clinical or radiological signs of threatened or impending CBO, and 4) CBO prevention strategies.

RESULTS

Thirty-five studies were selected for the analysis from five hundred seventy-seven records. Results provided indications on clinical, radiological and dosimetric parameters possibly associated with higher risk of CBO. Endovascular procedures (artery occlusion and stenting) to prevent acute massive hemorrhage in high risk patients were discussed.

CONCLUSION

Literature data are still scarce with a low level of evidence. Nevertheless, the present work provides a comprehensive review useful for clinicians as a multidisciplinary pragmatic tool in their clinical practice.

Flow Diversion for the Treatment of Petrous Internal Carotid Artery Aneurysms

Petrous internal carotid artery (ICA) aneurysms are rare and pose a unique management dilemma. They are most commonly fusiform. They are difficult to treat surgically and typically not amenable to selective aneurysmal obliteration. The advent of flow diverters, such as the Pipeline endovascular device, has offered a new approach to these historically challenging lesions. The unique utility of flow diversion in treatment of petrous ICA aneurysms is reviewed and discussed.

Radiation-Induced Brain Aneurysms: Institutional Experience and State of the Art in the Contemporary Literature

BACKGROUND

Brain aneurysms (BAs) are the most common intracranial vascular condition, with an overall incidence of 1%-2%. Among the common causes of their initial formation and growth, the role of radiation therapy (RT) has been reported in some studies. The aim of the present study is to report the most relevant features of BA related to a previous cranial RT.

METHODS

Data deriving from 1 patient treated for RT-induced BA in our institution were added to reports of another 66 BAs retrieved from the literature. The following parameters were evaluated: age, sex, location, primary lesion, clinical presentation, dosage/amount of radiation delivered, type of treatment for the BA, dimension, morphology, chemotherapy, comorbidities, risk factors, and number of BAs.

RESULTS

The most commonly involved vessel was the internal carotid artery (34%). In general, the anterior circulation showed higher vulnerability compared with the posterior circulation and middle cerebral artery (56.7%). The average latency between RT and the first imaging showing the BA was 9.01 ± 6.85 years. Vessels coursing in the posterior cranial fossa showed a significant univariate association with lower X-ray dosages (P = 0.014) compared with the other locations. No statistically significant correlation between the continuous variables age, latency of BA appearance, RT delivered dose, and dimension of the BA was shown.

CONCLUSIONS

The apparent higher fragility of the vascular structures of the posterior cranial fossa was statistically outlined, and the X-ray dosage, the primary condition target of the RT, the age of the patients, and no statistically significant correlation were outlined. Biological factors could play a significant role.

Refractory De Novo Multiple Cerebral Aneurysms After Radiotherapy and Multistaged "Open" Surgical Treatment for Low-Grade Glioma During Long-Term Follow-Up: A Case Report and Review of the Literature

Background

Radiation-induced aneurysms have been previously reported; however, multiple and repeated de novo aneurysm formation chronologically and anatomically during long-term follow-up have not yet been observed. The pathogenesis of persistent radiation-induced vasculopathy is not fully understood.

Case Description

A 31-year-old woman presented with intraventricular hemorrhage due to rupture of a right internal carotid artery (ICA) aneurysm that developed 17 years after surgical resection of a low-grade glioma in the right frontal lobe and postoperative radiotherapy (focal, 50 Gy/25 fractions). During glioma follow-up, salvage surgery with adjuvant gamma knife therapy and chemotherapy (ranimustine, vincristine, temozolomide) were performed for recurrence of the glioma. The aneurysm was treated with endovascular coil embolization. However, she experienced repeated intraventricular hemorrhages, and angiography revealed a de novo ICA aneurysm. The de novo aneurysms were treated with endovascular surgery using coil embolization and stenting. At 2 years after the third hemorrhage, the surgical wound became dehiscent, probably due to wound infection, thus epicranial soft tissue reconstruction using vascularized skin flap was performed. Despite multistaged endovascular surgery for the ICA aneurysm, she experienced repeated subarachnoid and intraventricular hemorrhages. Angiography revealed a de novo aneurysm of the right posterior cerebral artery and basilar trunk. She underwent coil embolization and stenting. Despite active management with endovascular surgery and close follow-up, she died after an eighth consecutive intraventricular and intracerebral hemorrhage caused by a de novo large aneurysm of the posterior cerebral artery.

Conclusions

To the best of our knowledge, the present study is the first to report on of refractory and recurring de novo aneurysms treated by multistaged endovascular surgery during a long-term follow-up after radiotherapy and multistaged craniotomy for glioma.

Etiology and management of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma

Objective

To analyze the etiology of nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and evaluate the relevant management and rescue approaches.

Methods

Seventeen cases of nasopharyngeal hemorrhage caused by radiotherapy of NPC, treated between January 2015 and March 2018, were retrospectively analyzed to study the etiology of nasopharyngeal hemorrhage. The management and rescue strategies, including anterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization, were assessed for their effectiveness.

Results

Nasopharynx hemorrhage after radiotherapy of NPC was mainly associated with erosion of the internal carotid artery or maxillary artery by the tumor. Among the 17 cases, 11 patients were treated by digital subtraction arterial angiography embolization, and 3 were treated by endoscopic nasopharynx electrocoagulation. Overall, 13 patients survived, while 4 died.

Conclusion

Anterior and posterior nostril packing, endoscopic nasopharynx electrocoagulation, and digital subtraction angiography embolization are suitable for treating nasopharyngeal hemorrhage. However, effective hemostasis depends on early identification of the bleeding vessels.

Giant petrous internal carotid aneurysm causing epistaxis: A case report

Aneurysms of the internal carotid artery (ICA) arising from the petrous portion are extremely rare, and most cases are asymptomatic or cause a mass effect leading to palsy of the adjacent cranial nerves. In rupture cases, massive nasal and ear bleeding occurs, which may cause death. We describe a 73-year-old man with a giant ICA aneurysm arising from the petrous portion and presenting as epistaxis. The patient had no history of trauma or clotting disorders. Computed tomography angiography demonstrated a giant petrous carotid aneurysm and erosion of a part of the left temporal bone. The patient was treated by trapping of the aneurysm with high-flow bypass using a radial artery. From an anatomical view point, rupture of ICA aneurysms of this portion might be caused by thinness of the bone partition between the ICA and the sphenoidal sinus. It should be noted that petrous carotid aneurysms are usually asymptomatic but may cause massive epistaxis in cases of rupture.

Radiotherapy-related intracranial aneurysm: case presentation of a 17-year male and a meta-analysis based on individual patient data

PURPOSE

The aim of this study was to investigate the incidence, clinical profiles, latency, and outcomes of radiotherapy (RT)-related intracranial aneurysms, rare but often fatal complications of cranial irradiation.

METHODS

We reviewed all published individual patient data regardless of language, using survival analysis to make statistical inferences.

RESULTS

We examined a total of 58 patients with RT-related intracranial aneurysms, including one unpublished case presented here, of whom 74.1 % presented with rupture. In the study, 29.3 % were younger than 18 years. The mean age at which patients received the first course of RT was 34.8 ± 22.8 years old. The mean latency between initiating RT and presenting with aneurysm was 10.4 ± 8.5 years. Rapid death ensured in 24 % shortly after presentation. The only significant predictor of death was rupture. In those with a single aneurysm, 43.1 % were located at the internal carotid artery, while 15.5 % of patients had multiple aneurysms. A male-to-female ratio of 1.87, 0.5, and 1.32 was found in patients younger than age 52, 52 years of age or older, and all 58 patients, respectively. Older age when receiving RT and presentation with ruptured aneurysm were significantly associated with shorter latency.

CONCLUSIONS

RT-related intracranial aneurysms presented differently from classical ones based on age, sex, site, multiplicity, and type. Sex ratios differed with age. The younger age group showed a longer latency of occurrence of an aneurysm. Older patients and those who develop ruptured aneurysms presented earlier. Since rupture may affect outcome, early detection of aneurysms before rupture may save lives.

Radiation-Induced Petrous Internal Carotid Artery Aneurysm

Iatrogenic internal carotid artery aneurysm is a rare complication of irradiation. There are few reported cases in the literature. A case of radiation-induced petrous internal carotid artery aneurysm in a patient with nasopharyngeal cancer treated with radiotherapy is reported. The approach to managing such an aneurysm is discussed.

A Cross-Sectional Cohort Study of Cerebrovascular Disease and Late Effects After Radiation Therapy for Craniopharyngioma

BACKGROUND

The study objective was to describe radiation-induced vascular abnormalities, stroke prevalence, and stroke risk factors in survivors of childhood craniopharyngioma.

PROCEDURE

Twenty survivors of childhood craniopharyngioma who received radiotherapy (RT) were included in the study. A clinical history, quality of life assessment, cognitive functioning assessment, magnetic resonance angiogram or computed tomography angiogram, fasting lipid profile, and fasting glucose or hemoglobin A1c test were obtained.

RESULTS

Median age at diagnosis was 10.3 years and median age at time of study was 29.0 years. Vascular abnormalities were detected in six (32%) of 19 patients' angiograms (vascular stenosis, decreased artery size, aneurysm, cavernoma, and small vessel disease). Five (25%) of 20 patients experienced a stroke after RT. Median time since RT was 27.8 versus 9.1 years in patients with versus without vascular abnormalities (P = 0.02). A low level of high-density lipoproteiin (HDL) was present in 100% (5/5) of patients who had a post-RT stroke as compared with 13% (2/15) of patients who did not have any post-RT stroke (P = 0.02). Previous stroke had occurred in 0% (0/5) of patients receiving growth hormone (GH) replacement at the time of study, compared to 40% (6/15) of patients who were not receiving GH replacement (P = 0.09).

CONCLUSIONS

Patients with craniopharyngioma treated with RT have a high prevalence of stroke and vascular abnormalities, particularly those with low HDL and longer duration of time since RT. There is a trend to suggest that continual GH replacement may reduce the risk of stroke. These patients should undergo careful monitoring and aggressive modification of stroke risk factors.

Ruptured internal carotid artery aneurysm presenting with catastrophic epistaxis after repeated stereotactic radiotherapies for anterior skull base tumor: case reports and review of the literature

Objectives Radiation-induced aneurysm is a rare complication for head and neck tumors. Only seven cases of an aneurysm after stereotactic radiosurgery and/or stereotactic radiotherapy (SRT) have been described. We report two patients with a ruptured internal carotid artery (ICA) aneurysm presenting with catastrophic epistaxis after repeated SRT for an anterior skull base tumor.

Results Two male patients received repeated SRT in various combinations following surgery for an anterior skull base tumor. They presented with significant epistaxis due to rupture of the aneurysm of the ICA 6 and 77 months after the final SRT, respectively. The aneurysms were located within the radiation field. Preoperative angiography had revealed no aneurysms. Thus the aneurysms in these cases were most likely induced by the repeated SRT.

Conclusions This is a proven report of aneurysm formation following repeated SRT without conventional radiotherapy. SRT may be very effective to control malignant skull base tumors. However, the possible development of radiation-induced aneurysm of the ICA should be considered in the case of repeated SRT. The surviving patients who have received SRT should undergo sequential follow-up for possible vascular involvement.

Cavernous internal carotid artery aneurysm after radiotherapy presenting with external ophthalmoplegia

Cranial radiotherapy could cause several types of vasculopathies, which include atherosclerotic occlusive diseases, moyamoya disease, and aneurysm formation. To our knowledge, radiation-induced aneurysms of the internal carotid artery (ICA) are extremely rare. Here, we report a 68-year-old woman who presented with external ophthalmoplegia caused by radiotherapy after the transsphenoidal surgery for metastastic tumor of the clivus region, and the angiography demonstrated a giant aneurysm of the cavernous ICA. After the ICA ligation, the patient recovered well without brain ischemia with a 6-month-long follow-up. The present case is extremely rare with external opthalmoplegia caused by the giant cavernous ICA aneurysm, and the radiotherapy after transsphenoidal surgery might have been critical in the formation of the aneurysm.

Cervical-petrous internal carotid artery pseudoaneurysm presenting with otorrhagia treated with endovascular techniques

Cervical-petrous internal carotid artery (CP-ICA) pseudoaneurysms are rare and have different etiologies, presentations, and treatment options. A middle-aged patient with a history of chronic otitis media presented with acute otorrhagia and was found to have a left-sided CP-ICA pseudoaneurysm. The patient was a poor surgical candidate with difficult arterial access. The pseudoaneurysm was treated with stand-alone coiling via a left brachial approach with persistent contrast filling seen only in the aneurysm neck at the end of the procedure. The patient re-presented 12 days later with repeat hemorrhage and rapid enlargement of the neck remnant, and was treated with a covered stent via a transcervical common carotid artery cut-down. A covered stent may provide a more definitive treatment for CP-ICA pseudoaneurysms compared with standalone coiling.

Cervical-petrous internal carotid artery pseudoaneurysm presenting with otorrhagia treated with endovascular techniques

Cervical-petrous internal carotid artery (CP-ICA) pseudoaneurysms are rare and have different etiologies, presentations, and treatment options. A middle-aged patient with a history of chronic otitis media presented with acute otorrhagia and was found to have a left-sided CP-ICA pseudoaneurysm. The patient was a poor surgical candidate with difficult arterial access. The pseudoaneurysm was treated with stand-alone coiling via a left brachial approach with persistent contrast filling seen only in the aneurysm neck at the end of the procedure. The patient re-presented 12 days later with repeat hemorrhage and rapid enlargement of the neck remnant, and was treated with a covered stent via a transcervical common carotid artery cut-down. A covered stent may provide a more definitive treatment for CP-ICA pseudoaneurysms compared with standalone coiling.

Postirradiated carotid blowout syndrome in patients with nasopharyngeal carcinoma: a case-control study

BACKGROUND

Carotid blowout syndrome is one of the most devastating complications of nasopharyngeal carcinoma (NPC) therapy.

METHODS

A retrospective review was conducted from January 2004 to April 2013. Thirty-one patients with carotid blowout syndrome were enrolled and a case control study was conducted to analyze the risk factors.

RESULTS

When a comparison was made between the carotid blowout syndrome and matched non-bleeding group, there was a significantly higher local recurrence rate and prevalence of skull base osteoradionecrosis (ORN) in the carotid blowout syndrome group compared to those of the control group (both p < .001). The hazard ratio of carotid blowout syndrome was 3.599 between patients with or without reirradiation (95% confidence interval, 1.465-8.839; p = .005, adjusted for nasopharyngectomy and chemotherapy) using a Cox proportional hazard model.

CONCLUSION

Reirradiation and skull base ORN are strong predisposing factors for carotid blowout syndrome, and therefore they should be mentioned in the informed consent form before treatment.

Formation and Rupture of the Internal Carotid Artery Aneurysm after Multiple Courses of Intensity-Modulated Radiation Therapy for Management of the Skull Base Ewing Sarcoma/PNET: Case Report

Background Aneurysm formation after stereotactic irradiation of skull base tumors is rare. The formation and rupture of an internal carotid artery (ICA) aneurysm in a patient with skull base Ewing sarcoma/primitive neuroectodermal tumor (PNET), who underwent surgery followed by multiple courses of intensity-modulated radiation therapy (IMRT) and chemotherapy, is described.

Case Description A 25-year-old man presented with a sinonasal tumor with intraorbital and intracranial growth. At that time cerebral angiography did not reveal any vascular abnormalities. The lesion was resected subtotally. Histopathologic diagnosis was Ewing sarcoma/PNET. The patient underwent multiple courses of chemotherapy and three courses of IMRT at 3, 28, and 42 months after initial surgery. The total biologically effective dose delivered to the right ICA was 220.2 Gy. Seven months after the third IMRT, the patient experienced profound nasal bleeding that resulted in hypovolemic shock. Angiography revealed a ruptured right C4–C5 aneurysm and irregular stenotic changes of the ICA. Lifesaving endovascular trapping of the right ICA was done. The patient recovered well after surgery but died due to tumor recurrence 6 months later.

Conclusion Excessive irradiation of the ICA may occasionally result in aneurysm formation, which should be borne in mind during stereotactic irradiation of malignant skull base tumors.

Coronaric stent-graft deployment in the treatment of carotid blowout

"Carotid blowout syndrome" is defined as a hemorrhage caused by rupture of the carotid artery and its branches, and may be a severe complication of rhinopharyngeal carcinoma. This study aimed to highlight the usefulness and versatility of endovascular stent-graft placement as a rescue treatment in life-threatening carotid blowout syndrome. We describe the unconventional use of a 6 × 5 mm balloon-expandable coronaric covered stent in a patient with a diagnosis of spinocellular rhinopharyngeal carcinoma, followed by carotid blowout syndrome. Although long-term follow-up is needed to assess the eventuality of bleeding recurrence, the immediate clinical results were satisfactory.

Simultaneous occurrence of subarachnoid hemorrhage and epistaxis due to ruptured petrous internal carotid artery aneurysm: association with transsphenoidal surgery and radiation therapy: case report

A 62-year-old woman presented with simultaneous subarachnoid hemorrhage (SAH) and massive epistaxis. The patient had been treated for pituitary prolactinoma by two transsphenoidal surgeries, gamma knife radiosurgery, and conventional radiation therapy since age 43 years. Cerebral angiography showed left petrous internal carotid artery (ICA) aneurysm with slight stenosis on the adjacent left petrous ICA. She underwent superficial temporal artery-middle cerebral artery (STA-MCA) double anastomosis with endovascular internal trapping without complication the day after onset. Postoperative course was uneventful; the patient did not develop symptomatic vasospasm, recurrent epistaxis, or cerebrospinal fluid rhinorrhea. Postoperative angiography demonstrated complete disappearance of the aneurysm with patent STA-MCA anastomosis. The patient was discharged 2 months after surgery without neurological deficit. The present case is extremely rare with simultaneous onset of SAH and epistaxis caused by ruptured petrous ICA aneurysm. The transsphenoidal surgeries and radiation therapies might have been critical in the formation of the petrous ICA aneurysm.

Salvage reirradiaton with stereotactic body radiotherapy for locally recurrent head-and-neck tumors

PURPOSE

In this study, we present our results of reirradiation of locally recurrent head-and-neck cancer with image-guided, fractionated, frameless stereotactic body radiotherapy technique.

METHODS AND MATERIALS

From July 2007 to February 2009, 46 patients were treated using the CyberKnife (Accuray, Sunnyvale, CA) at the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey. All patients had recurrent, unresectable, and previously irradiated head-and-neck cancer. The most prominent site was the nasopharynx (32.6%), and the most common histopathology was epidermoid carcinoma. The planning target volume was defined as the gross tumor volume identified on magnetic resonance imaging and computed tomography. There were 22 female and 24 male patients. Median age was 53 years (range, 19-87 years). The median tumor dose with stereotactic body radiotherapy was 30 Gy (range, 18-35 Gy) in a median of five (range, one to five) fractions.

RESULTS

Of 37 patients whose response to therapy was evaluated, 10 patients (27%) had complete tumor regression, 11 (29.8%) had partial response, and 10 (27%) had stable disease. Ultimate local disease control was achieved in 31 patients (83.8%). The overall survival was 11.93 months in median (ranged, 11.4-17.4 months), and the median progression free survival was 10.5 months. One-year progression-free survival and overall survival were 41% and 46%, respectively. Grade II or greater long-term complications were observed in 6 (13.3%) patients. On follow-up, 8 (17.3%) patients had carotid blow-out syndrome, and 7 (15.2%) patients died of bleeding from carotid arteries. We discovered that this fatal syndrome occurred only in patients with tumor surrounding carotid arteries and carotid arteries receiving all prescribed dose.

CONCLUSIONS

Stereotactic body radiotherapy is an appealing treatment option for patients with recurrent head-and-neck cancer previously treated with radiation to high doses. Good local control with considerable 1-year survival is achieved with a relatively high rate of morbidity and related mortality.

Radiation carotid blowout syndrome in nasopharyngeal carcinoma: angiographic features and endovascular management

OBJECTIVE

To report clinical manifestations, angiographic features, and outcomes of endovascular management in 14 patients with 15 radiation carotid blowout syndromes of nasopharyngeal carcinomas.

STUDY DESIGN AND SUBJECTS

Retrospective chart review of 14 patients with nasopharyngeal carcinomas (mean age 49 years) with 15 radiation carotid blowout syndromes who had undergone endovascular embolization to manage oronasal bleeding in the past 10 years.

RESULTS

Average radiation dose to affected carotid artery was 73 gray units (latent period: 33 months). Radiation carotid blowout syndrome was detected in internal (n = 10), external (n = 4), or common carotid artery (n = 1). Detachable balloons were used in 11 affecting arteries for vascular occlusion; 4 were treated by liquid adhesives or coil. Endovascular treatment was successful in all 15 radiation carotid blowout syndromes with cessation of hemorrhage. One patient had hemiparesis after embolization. Mean clinical follow-up was 21 months.

CONCLUSION

Radiation carotid blowout syndrome in nasopharyngeal carcinoma may occur in various periods or arteries. Endovascular embolization provides both safe and effective management.

Placement of covered stents for carotid blowout in patients with head and neck cancer: follow-up results after rescue treatments

BACKGROUND AND PURPOSE

Placement of a covered stent to control carotid blowout (CB) in malignant tumors of the head and neck has been reported to be an effective treatment. However, it is not uncommon to encounter recurrent hemorrhage. The purpose of this study was to evaluate the follow-up results of patients treated with covered stents.

MATERIALS AND METHODS

We retrospectively reviewed the results of 7 consecutive patients who underwent placement of a covered stent to control CB. Most of them had poor wound healing because of previous irradiation, surgery, or both. The initial procedures were successful in all patients. Their clinical course was reviewed for rebleeding, additional endovascular treatments in recurrent cases, and outcomes.

RESULTS

Recurrence developed in 6 of 7 patients. The interval between the first procedure and the hemorrhagic event was from 3 to 44 days. In 6 patients who had a recurrent CB, 4 had rebleeding from the previous site of the stent, whereas 2 other patients experienced recurrent bleeding in a different area from the site of the stent. Additional endovascular treatments were carried out in all affected patients by another insertion of a covered stent (n = 3), coil embolization (n = 2), or insertion of a covered stent followed by permanent arterial occlusion (n = 1).

CONCLUSION

Placement of a covered stent in patients with head and neck cancer who sustain CB showed frequent rebleeding despite favorable initial rescue results. Recurrent CB at the previous stent site developed frequently in patients with uncontrolled wound infection. Concomitant or short-interval arterial trapping should be considered selectively in those conditions.

Treatment of profuse epistaxis in patients irradiated for nasopharyngeal carcinoma

BACKGROUND

Profuse epistaxis in patients with nasopharyngeal carcinoma (NPC) previously treated with radiotherapy (RT) can be life threatening. Surgical means to prevent rebleeding may at times be difficult and unsuccessful. We aim to investigate the characteristics of this group of patients and our experience of endovascular embolization technique in the management of epistaxis in this group of patients.

METHODS

A retrospective review of all nasopharyngeal carcinoma patients presented with profuse epistaxis during follow up after radiotherapy was carried out in a regional neurosurgical centre in Hong Kong. Seventeen patients were included for the analysis within the recent 6-year period. The age of patients was 55.5 +/- 8.358 years (mean +/- standard deviation). The sex ratio was 5:1 (M : F). Diagnostic catheter angiography was carried out in all 17 patients. Endovascular embolization was carried out in 11 patients with the joint decision of the otolaryngologist and neurointerventionist in charge .

RESULTS

Four patients underwent main trunk occlusion for internal carotid pseudoaneurysm. Seven patients underwent embolization of branches of external carotid artery. One patient required another session of external carotid artery embolization 1 month later. There was one inpatient death because of pneumonia and hepatic encephalopathy. With our protocol, there were only two patients (11.7%) with delayed rebleed at 2 and 5 months, respectively. Both patients had advanced diseases and died.

CONCLUSION

In irradiated patients with nasopharyngeal carcinoma presenting with profuse epistaxis, angiography had a high yield of pseudoaneurysm or hypervascularity and these lesions could be safely managed through endovascular embolization.

Transarterial embolization of acute external carotid blowout syndrome with profuse oronasal bleeding by N-butyl-cyanoacrylate

OBJECTIVES

Assess duration, efficacy, and safety of emergent transarterial embolization of acute external carotid blowout syndrome (ECBS) with N-butyl-cyanoacrylate.

METHODS

Medical records were reviewed for 16 patients (15 men, 1 woman; age range, 28-85 years) who had 17 acute ECBS events that presented with profuse transoronasal bleeding. Predisposing factors were carcinoma associated with surgery and/or radiotherapy (n = 14) or trauma (n = 3). Affected arteries were the internal maxillary artery (n = 5), superior thyroid artery (n = 4), lingual artery (n = 4), facial artery (n = 2), or ascending pharyngeal artery (n = 2).

RESULTS

Endovascular treatment successfully obliterated all acute ECBSs with cessation of profuse hemorrhage. Mean duration of procedure was 54 minutes. Three patients had recurrent carotid blowout syndrome events, with 1 resulting death. Clinical follow-up range was 2 to 23 months.

CONCLUSIONS

Transarterial N-butyl-cyanoacrylate embolization can successfully manage acute ECBS with profuse hemorrhage. The technique is both efficient and safe, and the procedure can be rapidly completed.

Intracranial aneurysm following radiation therapy during childhood for a brain tumor. Case report and review of the literature

Ionizing radiation therapy is associated with pathological vascular changes in intracranial vessels, most commonly in the form of vessel thrombosis and occlusion. The development of an intracranial aneurysm following such therapy, however, is far less common. In this report the authors describe a 24-year-old man in whom a distal middle cerebral artery aneurysm developed 15 years after radiotherapy, which was given as adjuvant treatment following resection of a medulloblastoma. The patient underwent a craniotomy for microsurgical trapping of the aneurysm and was discharged without any neurological deficit. This case serves to remind clinicians of the possibility, albeit rare, that intracranial aneurysms may form following cranial radiotherapy.

Radiation acute carotid blowout syndromes of the ascending pharyngeal and internal carotid arteries in nasopharyngeal carcinoma

Acute carotid blowout syndrome (CBS) was defined as free rupture of the carotid artery associating with catastrophic hemorrhage. Most radiation acute CBSs in nasopharyngeal carcinoma (NPC) are found in petrous segment of the internal carotid artery (ICA) because of high-dose radiation in this area associated with nearby osteonecrosis. The occurrence of acute CBSs in the small branch of the external carotid artery and cervical ICA following radiotherapy in NPC patient is very rare. We present a rare case of NPC with radiation acute CBSs in the ascending pharyngeal and cervical ICA in a 3-month interval that were successfully managed by endovascular embolization.

Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature

A 42-year-old female presented with subarachnoid hemorrhage (SAH), presumably from a radiation-induced anterior communicating artery aneurysm. Six years earlier, she had undergone radiation treatment for an optic glioma that was diagnosed based on imaging criteria. The aneurysm was successfully clipped, and the optic glioma was biopsied to verify the diagnosis histologically. Radiation-induced cerebral aneurysms often manifest with a fatal SAH. These aneurysms typically develop in the field of radiation and are diagnosed a mean of 8.52 years after radiation. Rarely, the aneurysm sac thromboses spontaneously. Clipping or coiling of the aneurysm can be an effective treatment.

Preliminary results of radiation dose escalation for locally advanced nasopharyngeal carcinoma

PURPOSE

To study the safety and efficacy of dose escalation in tumor for locally advanced nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

From September 2000 to June 2004, 50 patients with T3-T4 NPC were treated with intensity-modulated radiotherapy (IMRT). Fourteen patients had Stage III and 36 patients had Stage IVA-IVB disease. The prescribed dose was 76 Gy to gross tumor volume (GTV), 70 Gy to planning target volume (PTV), and 72 Gy to enlarged neck nodes (GTVn). All doses were given in 35 fractions over 7 weeks. Thirty-four patients also had concurrent cisplatin and induction or adjuvant PF (cisplatin and 5-fluorouracil).

RESULTS

The average mean dose achieved in GTV, GTVn, and PTV were 79.5 Gy, 75.3 Gy, and 74.6 Gy, respectively. The median follow-up was 25 months, with 4 recurrences: 2 locoregional and 2 distant failures. All patients with recurrence had IMRT alone without chemotherapy. The 2-year locoregional control rate, distant metastases-free and disease-free survivals were 95.7%, 94.2%, and 93.1%, respectively. One treatment-related death caused by adjuvant chemotherapy occurred. The 2-year overall survival was 92.1%.

CONCLUSIONS

Dose escalation to 76 Gy in tumor is feasible with T3-T4 NPC and can be combined with chemotherapy. Initial results showed good local control and survival.

Aneurysms of the petrous internal carotid artery: anatomy, origins, and treatment

Aneurysms arising in the petrous segment of the internal carotid artery (ICA) are rare. Although the causes of petrous ICA aneurysms remain unclear, traumatic, infectious, and congenital origins have been implicated in their development. These lesions can be detected incidentally on routine neuroimaging. Patients can also present with a wide spectrum of signs and symptoms, including cranial nerve palsies, Horner syndrome, pulsatile tinnitus, epistaxis, and otorrhagia. The treatment of petrous ICA aneurysms remains challenging. Treatment options include close observation, endovascular therapies, and surgical trapping with or without revascularization. Management dilemmas exist, particularly for incidental lesions found in asymptomatic patients. The authors review the literature and discuss the anatomy of the petrous ICA as well as the pathophysiological features of aneurysms arising in this region, and they propose a management paradigm with current treatment options.

Endovascular treatment of epistaxis in patients irradiated for nasopharyngeal carcinoma

Posterior epistaxis commonly occurs after radiotherapy for nasopharyngeal carcinoma and is difficult to treat. Endovascular treatment was carried out on 11 previously irradiated patients who presented with intractable epistaxis over 4 years. We review their outcomes. All had significant angiographic abnormalities. Ten patients underwent intra-arterial embolization and, in one patient, balloon occlusion of an arterial pseudo-aneurysm was performed. Two patients (18%) suffered permanent neurological deficits. Two (18%) required further embolization in the first 2 days and one (9%) after the first month. One patient (9%) is still alive 4 years later. Only three (27%) died from haemorrhage. The mean survival duration after treatment was 225 days. Post-radiation anatomical changes often make conventional treatment of epistaxis difficult. Endovascular treatment maps out aberrant vascular anatomy and identifies the offending vessel. Our results show that the survival benefit of this treatment outweighs the risks, as such haemorrhage is often fatal.