Abstract
Intracavernous carotid hemorrhage is a rare cause of epistaxis. We present a case of epistaxis caused by postradiotherapy and nontraumatic cavernous internal carotid artery (ICA) hemorrhage. An 80-year-old man was admitted to our hospital with a one week history of recurrent left-sided epistaxis and a past history of radiotherapy after radical maxillectomy. Emergent angiography revealed a leak in the cavernous segment of the ICA and subsequent detachable balloon occlusion embolization of the left internal carotid artery was performed without sequelae. We conclude that carotid artery hemorrhage must be considered in the differential diagnosis of profuse and recurrent epistaxis, especially for patients after craniofacial radiotherapy. ICA embolization is the definitive treatment provided cross circulation is adequate.
1
Introduction
Epistaxis is the most common emergency in otorhinolaryngology . It may result from a multitude of causes, both local and systemic. Most cases are due to bleeding from the anterior nasal septum and are easily managed with local measures. Posterior epistaxis is more severe, with a distinct source of bleeding often difficult to localize. Common etiologic factors include mucosal dryness, digital trauma, nasal septal deviation, anticoagulation drug in use, and hypertension. Uncommon etiologic factor for epistaxis is trauma that, together with vascular abnormalities, accounts for fewer than 5% of severe cases .
Rupture of postirradiated great vessels is rare. Fewer than 10 cases have been reported in the English literature . The most common presentation for nontraumatic and postirradiated cavernous internal carotid artery (ICA) rupture is pseudoaneurysm. Several cases in the literature report this complication of craniofacial radiotherapy, all in those with nasopharyngeal carcinoma .
Patients with epistaxis who fail initial conservative therapy require endoscopic cautery, surgical ligation, or transarterial embolization of the nasal cavity vascular supply. Embolization is primarily targeted at the branches arising from the internal maxillary artery . Today, embolization is an accepted treatment of anterior and posterior epistaxis, where available. This report illustrates a case of epistaxis caused by a radiation-induced and nontraumatic ICA hemorrhage without presenting pseudoaneurysm.
2
Case report
An 80-year-old man was admitted in to our hospital with a 1-week history of recurrent left-sided epistaxis. Eleven years ago, the patient underwent a radical maxillectomy for squamous cell carcinoma of the maxillary antrum. Postoperative radiotherapy had been given according to the regulation dose. Two years ago, he received a course of γ knife therapy for metastasis in the left temporal lobe of the brain.
The initial physical examination showed unremarkable. Contrast-enhanced computed tomography and magnetic resonance imaging (MRI) scans revealed no hemorrhagic focus. Interestingly, the MRI scan revealed that the lateral wall of the sphenoid sinus was quite close to the ICA ( Fig. 1 A ). A review of his previous films revealed that only a thin layer of soft tissue separated the ICA from the lateral wall of the sphenoid sinus ( Fig. 1 B).
During the endoscopic operation, osteonecrosis was found on the anterior skull base with a defect area of 2 × 3 cm 2 . Cerebral dura mater was exposed with obvious pulsation. The operation ended by anterior and posterior packing with yarn.
The patient was transferred to Shanghai Renji Hospital Neurosurgery Department, where an emergent angiogram revealed much leakage in the cavernous segment of the ICA. After a successful balloon occlusion test with hypotensive challenge, detachable balloon occlusion embolization of the left ICA was performed. Two balloons were placed, respectively, on the proximal and distal ends of that segment. The patient had no neurologic deficit as a result of the procedure. A follow-up at 6 months demonstrated no symptoms of epistaxis or neurologic deficit.
2
Case report
An 80-year-old man was admitted in to our hospital with a 1-week history of recurrent left-sided epistaxis. Eleven years ago, the patient underwent a radical maxillectomy for squamous cell carcinoma of the maxillary antrum. Postoperative radiotherapy had been given according to the regulation dose. Two years ago, he received a course of γ knife therapy for metastasis in the left temporal lobe of the brain.
The initial physical examination showed unremarkable. Contrast-enhanced computed tomography and magnetic resonance imaging (MRI) scans revealed no hemorrhagic focus. Interestingly, the MRI scan revealed that the lateral wall of the sphenoid sinus was quite close to the ICA ( Fig. 1 A ). A review of his previous films revealed that only a thin layer of soft tissue separated the ICA from the lateral wall of the sphenoid sinus ( Fig. 1 B).
