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Table of Contents    
CASE REPORT
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 485-490

Extracranial–intracranial high-flow bypass for post-traumatic cavernous carotid pseudo-aneurysm presenting with epistaxis: Case report


1 Department of Surgery, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India
2 Department of Surgery; Department of Neurosurgery and Gamma Knife Radiosurgery, P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. Basant K Misra
Department of Surgery, Department of Neurosurgery and Gamma Knife Radiosurgery, P.D. Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai - 400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.257994

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 » Abstract 


We present a case of posttraumatic cavernous carotid pseudo-aneurysm presenting with epistaxis, in which microsurgical treatment was the treatment of choice as endovascular treatment was perceived to be too risky because of a bone fragment impinging on the wall of the aneurysm. The patient was successfully managed by a high-flow, radial artery, external carotid artery-middle cerebral artery bypass and trapping of the internal carotid artery. The patient was discharged one week later without any further episode of hemorrhage.


Keywords: High-flow, radial artery, external carotid artery-middle cerebral artery bypass, carotid, cavernous, epistaxis, pseudo-aneurysm
Key Message: The current case reports a large intracavernous carotid pseudo-aneurysm as a rare cause of epistaxis that requires a high index of suspicion in the right clinical setting and the need for extracranial–intracranial high-flow bypass in selected cases of cavernous carotid aneurysm.


How to cite this article:
Kankane VK, Warade AG, Misra BK. Extracranial–intracranial high-flow bypass for post-traumatic cavernous carotid pseudo-aneurysm presenting with epistaxis: Case report. Neurol India 2019;67:485-90

How to cite this URL:
Kankane VK, Warade AG, Misra BK. Extracranial–intracranial high-flow bypass for post-traumatic cavernous carotid pseudo-aneurysm presenting with epistaxis: Case report. Neurol India [serial online] 2019 [cited 2019 Jul 16];67:485-90. Available from: http://www.neurologyindia.com/text.asp?2019/67/2/485/257994




Medical intervention in epistaxis is only needed in approximately 6% of the patients as cases of massive epistaxis are rare.[1] Digital trauma to the nasal mucosa, extreme dryness of the nasal cavity, a nasal foreign body, hypertension, anticoagulation, and blood dyscrasia are some of the common causes of epistaxis.[2],[3] Trauma and vascular abnormalities account for less than 5% of all cases of epistaxis.[3] Although head trauma is a well-known cause of epistaxis, epistaxis resulting from a traumatic pseudo-aneurysm of the internal carotid artery (ICA) is relatively rare. We present a case of posttraumatic cavernous carotid pseudo-aneurysm, in which microsurgical treatment was the treatment of choice as endovascular treatment was perceived to be too risky because of a bone fragment impinging on the wall of the aneurysm. Despite significant advances in the endovascular treatment of cerebral aneurysms[4],[5] and flow-diverter becoming the preferred treatment of cavernous carotid aneurysms,[6] the present case demonstrates the occasional need for an extracranial–intracranial (EC–IC) bypass even in proximal ICA aneurysms.


 » Case Report Top


A 57-year old gentleman was referred to our institution for further management of a cavernous ICA pseudo-aneurysm. The patient was previously involved in a road traffic accident and had sustained head injury one month back with complaints of profuse recurrent epistaxis, decreased vision in the right eye (with the present vision being perception of light), and left hemiparesis. The epistaxis had stopped at the time of admission.

The patient's hemoglobin level at admission was 10.7 g/dl and the coagulation profile was normal. Computed tomography angiography (CTA) of the brain and cerebral digital subtraction angiography (DSA) demonstrated a broad-neck, pseudo-aneurysm measuring 19 × 15 mm, arising from the cavernous segment of the right ICA and projecting medially and inferiorly into the sphenoid sinus. There was fracture of the lateral wall of sphenoid sinus bilaterally and a bone fragment was impinging on the aneurysmal wall [Figure 1] and [Figure 2]. The patient tolerated the balloon test occlusion.
Figure 1: CT angiography of the brain showing a broad-necked pseudo-aneurysm measuring 19 x 15 mm arising from the cavernous segment of right internal carotid artery and projecting infero-medially into the sphenoid sinus. There was fracture of lateral wall of the sphenoid sinus bilaterally and a bone fragment was impinging on the pseudo-aneurysmal wall

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Figure 2: Postoperative CT angiography revealing graft patency with good opacification of the right middle cerebral artery and its branches. Pseudo-aneurysm in the right cavernous internal carotid artery is not visualized

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The patient was referred to our endovascular colleagues but intervention with flow-diverter was perceived to be too risky in view of the bone fragment impinging into the aneurysmal wall. Hence, the patient was managed microsurgically with EC–IC high-flow bypass (external carotid artery to M2 segment of middle cerebral artery) using a radial artery graft. After the graft patency was confirmed by an intraoperative indocyanine green video-angiography (ICGVA), the right internal carotid artery was trapped, ligated at neck, and was clipped just proximal to the ophthalmic artery [operative video 1 and serial operative [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10] On the first postoperative day, the CT angiography revealed graft patency with a normal cerebral circulation and nonopacification of the pseudo-aneurysm [Figure 2]. The patient had no further epistaxis, and the vision remained compromised but hemiparesis improved. At the 2-month follow up, there was no episode of epistaxis, his hemiparesis had completely improved but vision remained compromised.
Figure 3: Sylvian fissure dissection and exposure of the recipient artery, and the M2 segment of MCA

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Figure 4: Incision given between the temporarily clipped M2 segment of MCA

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Figure 5: S End-to-side anastomosis of the radial artery graft to M2

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Figure 6: Aneurysmal neck exploration and preparation of the external carotid artery

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Figure 7: End-to-side anastomosis of the radial artery graft to external carotid artery

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Figure 8: Graft patency confirmed by Indocynine green video angiography

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Figure 9: Anterior clinoid process drilling to expose the ICA proximal to the ophthalmic artery

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Figure 10: Trapping of ICA proximal to the ophthalmic artery

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 » Discussion Top


Only 3–5 per cent of all intracranial aneurysms originate from the cavernous ICA.[7] Most of these cases are attributable to trauma, with an associated mortality rate of up to 50%.[8] Trauma-induced vessel wall defect in the presence of constant arterial pressure may result in the blood dissecting into the surrounding area and forming a perfused sac (pseudo-aneurysm). A direct communication exists between the lumen of the vessel and the sac of the pseudo-aneurysm, with blood flowing through the defect in the vessel wall. Therefore, the risk of rupture is higher in a pseudo-aneurysm than in an aneurysm of a similar size due to inadequate support of the pseudo-aneurysm wall.

Most cases of pseudo-aneurysms occur after severe head injuries associated with fracture of the skull base, and following the occurrence of iatrogenic trauma after radical cavernous sinus dissection, although postinfectious and spontaneous pseudo-aneurysms have also been described.[9] Cavernous carotid pseudo-aneurysms may either be asymptomatic or rupture into the sphenoid sinus and present with delayed torrential epistaxis[10],[11] [Table 1]. Recurrent epistaxis can occur, as a small tear of the ICA can temporarily seal off from a hematoma within the enclosure of the sphenoid sinus.[12] The cavernous ICA has been observed to protrude into the lateral wall of the sphenoid sinus in 70% of the cadaveric specimens, as it is intimately related to this sinus.[13] The bony covering over the cavernous ICA within the sphenoid sinus measures less than 1 mm in 66% of the cases, and does not exist in 4% of them.[14] The thin tissue interface between these structures, therefore, predisposes to cavernous ICA injury in the cases sustaining a trauma and those undergoing sphenoid sinus surgery.[3] The medially and inferiorly directed aneurysmal sac in the present case, situated away from the laterally situated cranial nerves adjacent to the cavernous sinus, probably accounted for the absence of concurrent cranial nerve palsies in our patient. A hematoma in the sphenoid sinus suggests a dehiscent sinus wall, and any fracture of the sphenoid sinus (as seen in our patient) or the sella turcica should alert the surgeons and radiologists regarding the possibility of a traumatic intracavernous ICA pseudo-aneurysm existing. Therefore, a high index of suspicion for the presence of this condition is warranted. Carotid angiography is the gold standard for the elicitation of the diagnosis, and is mandatory to determine the feasibility of endovascular therapy or surgery.[15] The three-dimensional CTA is a less invasive alternative than the conventional catheter angiography and is usually done as the initial investigation of choice. CTA may be rapidly performed and has the ability to detect a pseudo-aneurysm, assess the surrounding anatomical bony structures, as well as aid in planning further management.
Table 1: Review of Literature

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Several strategies have been advocated for the management of symptomatic cavernous carotid aneurysm, including sacrificing the parent artery.[16] However, sacrificing the parent artery may not be tolerated by the patient and could result in cerebral hypoperfusion and ischemia. Despite angiography showing a good cross-flow from the contralateral cerebral hemisphere during the balloon test occlusion in our case, the parent artery occlusion may still place the patient at the risk of stroke.[17],[18],[19] Endovascular management of the proximal ICA aneurysm with a flow-diverter is an attractive and less invasive option, and hence, was considered as the firstline of management in the present case.

Flow diversion is a novel method of therapy wherein an endoluminal sleeve, the flow diverter stent, is placed across the neck of complex aneurysm to curatively reconstruct the abnormal vasculature. Cherian et al., presented the first Indian single center experience with the pipeline embolization device (PED) and the 6-month follow-up results of 5 patients. PED for complex and recurrent aneurysms is technically feasible and a safe option, offers a low complication rate, and provides a definitive vascular reconstruction. Pipeline embolization devices can be used without fear of occlusion of the covered eloquent side branches and perforators.[20]

Flow diverters (FDs) are the one of latest features in the series of advancements in the reconstructive endovascular treatment of aneurysms. Various devices such as silk flow diverters, flow re-direction endoluminal devices (FREDs), and PEDs have been tried in the treatment of giant aneurysms. Flow diverters cause endoluminal reconstruction, change the flow dynamics in and out of the aneurysm, and subsequently, induce thrombosis within the aneurysmal sac. Later, neointimal proliferation occurs, which eventually covers the stent leading to restructuring of the parent artery. This prevents the parent artery sacrifice and spares the perforator arteries. Subsequently, the aneurysm gets thrombosed and the sac shrinks around the stent relieving the mass effect. Although stasis may be seen immediately, complete resolution of the aneurysm can take a long time. The major advantage of a FD is the nonrequirement for catheterization of the delicate aneurysmal sac, thus reducing the risk of rupture. In complex aneurysms, it is a single step procedure, unlike the conventional method which would need numerous coil deployments and repeated repositioning of the microcatheter.[21],[22]

Giant intradural aneurysms, whether treated or not, may have a poor clinical outcome.[21],[22] The outcome following endovascular treatment of these lesions is better than its natural history if the aneurysm left untreated. However, the endovascular treatment may often be associated with high complication rates and a low chance of cure.[23] The uniquely characteristic pathological anatomy of the aneurysm, and a bone fragment impinging into the aneurysm wall, made the present case too risky and unsuitable for endovascular treatment, and hence, it was successfully managed with an EC–IC bypass and a proximal ICA occlusion.


 » Conclusion Top


Although intracavernous pseudo-aneurysms are extremely rare in isolated sphenoid fractures, they must be considered in the differential diagnosis when the patient has significant epistaxis with a previous history of head trauma. As these lesions are potentially lethal, an early detection, together with emergent treatment, is imperative. Despite significant advances in the endovascular treatment of cerebral aneurysms, and flow diverters becoming the preferred treatment of cavernous carotid aneurysms, the present case demonstrates the occasional need for an EC–IC bypass followed by proximal ICA occlusion, even in proximal ICA aneurysms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

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2.
Katsevman GA, Braca JA 3rd, Welch KC, Ashley WW Jr. 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. World Neurosurg 2016;92:585.  Back to cited text no. 2
    
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Weber W, Nahser HC, Henkes H, Berg-Dammer E, Kühne D. Pseudoaneurysm of the extracranial internal carotid artery. Treatment by stent and coil implantation. Nervenarzt 1999;70:870-7.  Back to cited text no. 4
    
5.
Shames ML, Davis JW, Evans AJ. Endoluminal stent placement for the treatment of traumatic carotid artery pseudoaneurysm: Case report and review of the literature. J Trauma 1999;46:724-6.  Back to cited text no. 5
    
6.
Giorgianni A, Pellegrino C, Minotto R, Mercuri A, Baruzzi F, Cantoni A, et al. Flow-diverter stenting in post-traumatic pseudoaneurysm of cavernous internal carotid artery with epistaxis. Interv Neuroradiol 2015;21:325-8.  Back to cited text no. 6
    
7.
Bars HW, Blackwood W, Meadows SP. Intracavernous carotid aneurysms. A clinical-pathological report. Brain 1971;94:607-22.  Back to cited text no. 7
    
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Wang AN, Winfield JA, Güçer G. Traumatic internal carotid aneurysm with rupture into the sphenoid sinus. Surg Neurol 1986;25:77-81.  Back to cited text no. 8
    
9.
Katzir M, Gil Z, Cohen JE, Sviri GE. Cavernous carotid artery pseudoaneurysm following a radical cavernous sinus resection. J Neurol Surg Rep 2016;7:102-5.  Back to cited text no. 9
    
10.
Bhatoe HS, Suryanarayana KV, Gill HS. Recurrent massive epistaxis due to traumatic intracavernous internal carotid artery aneurysm. J Laryngol Otol 1995;109:650-2.  Back to cited text no. 10
    
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Adeel M, Ikram M. Post-traumatic pseudoaneurysm of internal carotid artery: A cause of intractable epistaxis. BMJ Case Rep 2012;2012:bcr0220125927.  Back to cited text no. 11
    
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Chandy MJ, Rajshekhar V. Nontraumatic intracavernous carotid aneurysm presenting with epistaxis. J Laryngol Otol 1989;103:425-6.  Back to cited text no. 12
    
13.
Renn WH, Rhoton AL., Jr. Microsurgical anatomy of the sellar region. J Neurosurg 1975;43:288-98.  Back to cited text no. 13
    
14.
Chambers EF, Rosenblum AE, Norman D, Newton TH. Traumatic aneurysms of cavernous internal carotid artery with secondary epistaxis. Am J Neuroradiol 1981;2:405-9.  Back to cited text no. 14
    
15.
Kim JY, Farkas J, Putman CM, Varvares M. Paraclinoid internal carotid artery aneurysm presenting as massive epistaxis. Ann Otol Rhinol Laryngol 2000;109:782-6.  Back to cited text no. 15
    
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Misra BK. Treatment of giant intracranial aneurysms: What is the best option? Neurol India 2015;63:138-41.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Mathis JM, Barr JD, Jungreis CA, Yonas H, Sekhar LN, Vincent D, et al. Temporary balloon test occlusion of the internal carotid artery: Experience in 500 cases. Am J Neuroradiol 1995;16:749-54.  Back to cited text no. 17
    
18.
Lempert TE, Halbach VV, Higashida RT, Dowd CF, Urwin RW, Balousek PA, et al. Endovascular treatment of pseudoaneurysms with electrolytically detachable coils. AJNR Am J Neuroradiol 1998;19:907-11.  Back to cited text no. 18
    
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Sridharan R, Low SF, Mohd MR, Kew TY. Intracavernous internal carotid artery psuedoaneurysm. Singapore Med J 2014;55:165-8.  Back to cited text no. 19
    
20.
Cherian MP, Yadav MK, Mehta P, Vijayan K, Arulselvan V, Jayabalan S. First Indian single center experience with pipeline embolization device for complex intracranial aneurysms. Neurol India 2014;62:618-24.  Back to cited text no. 20
[PUBMED]  [Full text]  
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Karapurkar AP, Lalla R. Giant aneurysms: Still in the quest of a perfect cure. Neurol India 2015;63:133-5.  Back to cited text no. 21
[PUBMED]  [Full text]  
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Bhaisora KS, Behari S, Godbole C, Phadke RV. Traumatic aneurysms of the intracranial and cervical vessels: A review. Neurol India 2016;64, Suppl S1:14-23.  Back to cited text no. 22
    
23.
Zhang Z, Lv X, Yang X, Shiqing MU, Wu Z, Shen C, et al. Endovascular management of giant aneurysms: An introspection. Neurol India 2015;63:184-9.  Back to cited text no. 23
[PUBMED]  [Full text]  


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
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