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Profuse epistaxis following sphenoid surgery: a ruptured carotid artery pseudoaneurysm and its management

Published online by Cambridge University Press:  23 May 2008

D Biswas ,
A Daudia ,
N S Jones  and
N S McConachie
D Biswas*
Affiliation:
Department of Otolaryngology and Head and Neck Surgery, University of Nottingham, UK
A Daudia
Affiliation:
Department of Otolaryngology and Head and Neck Surgery, University of Nottingham, UK
N S Jones
Affiliation:
Department of Otolaryngology and Head and Neck Surgery, University of Nottingham, UK
N S McConachie
Affiliation:
Department of Interventional Radiology, Queen's Medical Centre, University of Nottingham, UK
*
Address for correspondence: Mr D Biswas, Department of Otolaryngology and Head and Neck Surgery, Queens Medical Centre, University of Nottingham, Derby Road, Nottingham NG7 2UH, UK. Fax: +44 (0)1159709748 E-mail: drdbiswas@hotmail.com
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Abstract

Objective:

We report a rare case of iatrogenic pseudoaneurysm of the internal carotid artery secondary to endoscopic sphenoid surgery.

Method:

The management of this unusual complication and a review of the literature are presented.

Results:

A 65-year-old woman presented with intractable epistaxis four days following endoscopic sphenoid sinus surgery. Initial, conservative measures were unsuccessful in controlling bleeding. The clinical picture of delayed, severe epistaxis after a sphenoid sinus exploration raised the possibility of injury to the internal carotid artery and subsequent formation of a false aneurysm. The patient's pseudoaneurysm was managed, without visualising it, by packing the sphenoid sinus (achieved by palpating 1 cm above the shoulder of the posterior choana) in order to gain control of the haemorrhage, followed by endovascular occlusion.

Conclusion:

An awareness of this rare complication is essential in order to manage this life-threatening condition efficiently.

Keywords

Sphenoid SinusInternal Carotid ArteryEpistaxisPseudoaneurysm
Type
Clinical Records
Information
The Journal of Laryngology & Otology , Volume 123 , Issue 6 , June 2009 , pp. 692 - 694
Copyright
Copyright © JLO (1984) Limited 2008

Introduction

An iatrogenic pseudoaneurysm of the internal carotid artery secondary to transsphenoid or intrasphenoid endoscopic surgery is uncommon and may present with delayed, life-threatening epistaxis.Reference Hollis, McGlashan, Walsh and Bowdler1–Reference Lister and Sypert3 False aneurysms of the internal carotid artery can also develop after a head injury.Reference Tampieri, Atkinson, Daniel, Teitelbaum and Shemie4–Reference Celil, Engin, Orhan, Barbaros, Hakan and Adil6 Delayed epistaxis resulting from iatrogenic trauma to the sphenopalatine branch of the internal maxillary artery (as it crosses the anterior wall of the sphenoid sinus) during transsphenoidal surgery has also been reported.Reference Cockroft, Carew, Trost and Fraser7

Case report

A 65-year-old woman who had previously undergone a left maxillectomy for paranasal sinus malignant melanoma was being followed up with a magnetic resonance imaging (MRI) scan. This scan showed a mass in the pituitary fossa (Figure 1a), which was subsequently explored and biopsied endoscopically in another unit.

Fig. 1 (a) Axial computed tomography scan at the level of skull base and (b) angiogram (lateral view), showing a large right internal carotid artery pseudoaneurysm pointing into the right sphenoid sinus.

Four days after the endoscopic surgery, the patient presented with profuse epistaxis.

Nasal packing and inflated balloons in the nasopharynx failed to control the bleeding, and the patient was referred urgently to our unit. After transfer and resuscitation, the bleeding was stopped by packing the sphenoid sinus with oxidised cellulose. This was done ‘blind’ as the quantity of bleeding prevented the use of an endoscope or head light. The site to be packed was located by palpating the ‘shoulder’ of the posterior choana and packing approximately 1 cm above this.

Subsequent angiography showed a large right internal carotid artery pseudoaneurysm pointing into the right sphenoid sinus (Figure 1b). This was managed with multiple coils to occlude the internal carotid artery from just below the anterior choroidal artery (Figure 2). At the end of the procedure, the cross-flow from the left internal carotid artery was poor. The patient developed a right hemispherical stroke in evolution post-operatively; however, fortunately she recovered rapidly from her neurological deficit.

Fig. 2 (a) Angiography images in the antero-posterior view and (b) lateral view, showing multiple coils in situ, used to occlude the internal carotid artery (ICA).

Discussion

Most carotid aneurysms are secondary to head trauma.Reference Tampieri, Atkinson, Daniel, Teitelbaum and Shemie4, Reference Bavinzski, Killer, Knosp, Ferraz-Leite, Gruber and Richling5 The sudden onset of life-threatening epistaxis following sphenoid surgery should prompt suspicion of rupture of a carotid aneurysm.Reference Reddy, Lesiuk, West and Fewer2, Reference Lister and Sypert3, Reference Kai, Hamada, Nishi and Ushio8, Reference Vergez, Folia, Michenet, Rose, Lacroix-Loubes and Percodani9 Excessive bleeding during trans-sphenoidal surgery also raises this possibility, and imaging will help to establish the diagnosis.Reference Kai, Hamada, Nishi and Ushio8 Early involvement of an experienced rhinologist, an interventional radiologist and possibly a neurosurgeon is needed, after initial resuscitative measures. Angiography is required, both for diagnosis and for treatment (by endovascular occlusion or embolisation or stenting of the aneurysm).Reference Tampieri, Atkinson, Daniel, Teitelbaum and Shemie4–Reference Celil, Engin, Orhan, Barbaros, Hakan and Adil6 Angiography performed in patients with refractory bleeding should also include the external carotid artery if nothing abnormal is found in the internal carotid artery territory.Reference Cockroft, Carew, Trost and Fraser7 The optimal management is carotid occlusion, provided the patient has been able to tolerate a trial of occlusion to show an adequate cross-flow through the circle of Willis.Reference Bavinzski, Killer, Knosp, Ferraz-Leite, Gruber and Richling5, Reference Kai, Hamada, Nishi and Ushio8, Reference Vergez, Folia, Michenet, Rose, Lacroix-Loubes and Percodani9 Bypass surgery is required where the patient cannot tolerate the balloon occlusion test, although in an emergency situation a trial occlusion is not possible.Reference Bavinzski, Killer, Knosp, Ferraz-Leite, Gruber and Richling5, Reference Kai, Hamada, Nishi and Ushio8

  • • This paper describes a rare case of iatrogenic pseudoaneurysm of the internal carotid artery secondary to endoscopic sphenoid surgery, resulting in profuse epistaxis

  • • Any episode of torrential epistaxis after sphenoid surgery should raise the possibility of damage to the internal carotid artery

  • • Early diagnosis and treatment is needed in order to avoid exsanguination and to maintain circulation until interventional radiology can be undertaken

Conclusion

Any episode of torrential epistaxis after sphenoid surgery should raise the possibility of damage to the internal carotid artery. Awareness of this complication is important in order to recruit the appropriate help as soon as possible. Early diagnosis and treatment is needed in order to avoid exsanguination and to maintain circulation until interventional radiology can be performed.

Footnotes

Presented at the European Congress of Oto-Rhino-Laryngology (EUFOS), Head & Neck Surgery, July 2007, Vienna, Austria.

References

1 Hollis, LJ, McGlashan, JA, Walsh, RM, Bowdler, DA. Massive epistaxis following sphenoid sinus exploration. J Laryngol Otol 1994;108:171–3CrossRefGoogle ScholarPubMed
2 Reddy, K, Lesiuk, H, West, M, Fewer, D. False aneurysm of the cavernous carotid artery: a complication of transsphenoidal surgery. Surg Neurol 1990;33:142–5CrossRefGoogle ScholarPubMed
3 Lister, JR, Sypert, GW. Traumatic false aneurysm and carotid-cavernous fistula: a complication of sphenoidotomy. Neurosurgery 1979;5:473–5CrossRefGoogle ScholarPubMed
4 Tampieri, D, Atkinson, JD, Daniel, SJ, Teitelbaum, J, Shemie, SD. Posttraumatic pseudoaneurysm of the intracavernous internal carotid artery presenting with massive epistaxis. Pediatr Crit Care Med 2006;7:260–2Google Scholar
5 Bavinzski, G, Killer, M, Knosp, E, Ferraz-Leite, H, Gruber, A, Richling, B. False aneurysms of the intracavernous carotid artery – report of 7 cases. Acta Neurochir (Wien) 1997;139:37–43CrossRefGoogle ScholarPubMed
6 Celil, G, Engin, D, Orhan, G, Barbaros, C, Hakan, K, Adil, E. Intractable epistaxis related to cavernous carotid artery pseudoaneurysm: treatment of a case with covered stent. Auris Nasus Larynx 2004;31:275–8CrossRefGoogle ScholarPubMed
7 Cockroft, KM, Carew, JF, Trost, D, Fraser, RA. Delayed epistaxis resulting from external carotid artery injury requiring embolization: a rare complication of transsphenoidal surgery: case report. Neurosurgery 2000;47:236–9Google ScholarPubMed
8 Kai, Y, Hamada, J, Nishi, T, Ushio, Y. Successful treatment with bypass and interventional surgery for a ruptured pseudo carotid artery aneurysm after transsphenoidal surgery: a case report [in Japanese]. No Shinkei Geka 2001;29:241–5Google ScholarPubMed
9 Vergez, S, Folia, M, Michenet, F, Rose, X, Lacroix-Loubes, F, Percodani, J et al. Pseudoaneurysm of the internal carotid artery revelated by epistaxis: report of two cases [in French]. Rev Laryngol Otol Rhinol (Bord) 2005;126:151–4Google ScholarPubMed
Figure 0

Fig. 1 (a) Axial computed tomography scan at the level of skull base and (b) angiogram (lateral view), showing a large right internal carotid artery pseudoaneurysm pointing into the right sphenoid sinus.

Figure 1

Fig. 2 (a) Angiography images in the antero-posterior view and (b) lateral view, showing multiple coils in situ, used to occlude the internal carotid artery (ICA).