Case Report
Flow-diverter stenting in post-traumatic pseudoaneurysm of cavernous internal carotid artery with epistaxis
Interventional Neuroradiology 2015, Vol. 21(3) 325–328 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1591019915582154 ine.sagepub.com
Andrea Giorgianni, Carlo Pellegrino, Renzo Minotto, Anna Mercuri, Fabio Baruzzi, Alfredo Cantoni, Larissa Nocchi Cardim and Luca Valvassori
Abstract This paper is a case report of a young patient after a major head trauma causing multiple skull base fractures. The trauma occasioned pseudoaneurysm (PSA) from intracavernous C4 segment of left internal carotid artery (ICA) protruding in the sphenoidal sinus. After two months, two episodes of massive epistaxis occurred. Consequently, the post-traumatic PSA was treated, after carotid occlusion test, with flow-diverter stent positioning. A computed tomography angiography study performed in the following days showed complete resolution of the post-traumatic PSA lesion and ICA patency.
Keywords Flow-diverter stenting, post-traumatic pseudoaneurysm, internal carotid artery
Introduction Massive epistaxis is a serious event in the clinical management of patients who present internal carotid artery (ICA) lesions after a trauma. Mortality rate is high. Endovascular treatment is a good alternative to conventional surgical treatments of these lesions. Several neurointerventional methods can be used for the therapy. In this case report, we describe a flow-diverter stent (FDS) treatment in a post-traumatic ICA pseudoaneurysm (PSA) bleeding.
Case report A 21-year-old male was admitted to our hospital after a major trauma, presenting severe head injury. The patient was intubated before being transferred to the hospital, with a Glasgow Coma Scale score of 3. The initial computed tomography (CT) scan revealed multiple facial fractures and a cranial base fracture affecting the left greater sphenoid wing and lateral ethmoid masses. Fracture of lateral left orbital wall, frontal and bilateral maxillary and sphenoidal sinus occurred (Figure 1). The CT angiography (CTA) showed an anterior wall focal dilatation of 19 mm of C4 intracavernous segment, leading to the diagnosis of a traumatic PSA of the left ICA with infero-medial development into the left sphenoidal sinus (Figure 2). The final digital subtraction angiography (DSA) confirmed a little neck of 20 mm diameter PSA.
Subsequent check with CTA two days after the trauma showed volume reduction of PSA with a maximum diameter of 13 mm. Approximately one month later, the patient was discharged and transferred to the rehabilitation centre. Two months after the trauma, two episodes of massive epistaxis occurred. The new CTA control confirmed the presence of PSA and it was decided to treat the vascular lesion. In the angiographic suite, the occlusion test was performed with manual compression of left carotid and showed not good compensation from right internal carotid artery. Distal superselective catheterisation of the left ICA was carried out and we proceeded to the FDS placement (4 18 mm, P64, Phenox, Bochum, Germany). First control documents carotid axis occlusion; thereby, is administered a 7 ml Abciximab (ReoPro) bolus. Final control after procedure showed correct FDS positioning (Figure 3) and ICA patency. It was recommended maintenance with subsequent infusion of 4.5 ml in 200 ml of saline solution for 12 hours. No intraprocedural complications occurred. The CTA control confirmed the PSA resolution and the stent patency (Figure 4).
Radiology Department, Ospedale di Circolo Varese, Varese, Italy Corresponding author: Carlo Pellegrino, Department of Radiology, Help Institution, Ospedale di Circolo Varese, Viale Borri 57, 21100 Varese, Italy. Email: [email protected]
326 Treatment with dual antiplatelet therapy for a month and a single aggregation for the following three months was proposed.
Discussion Trauma accounts for less than 5% of all severe cases of epistaxis.1
Figure 1. CT scan showing fracture of lateral left orbital wall, frontal and bilateral maxillary and sphenoidal sinus.
Interventional Neuroradiology 21(3) An intimal tear resulting from trauma can be explained by wall dissection, which consequently leads to decreased blood flow inside the PSA and intraluminal thrombus formation. PSA of the cavernous ICA can be a source of massive and life-threatening epistaxis and they are related to traumatic, congenital, mycotic and inflammatory causes.2 Rarely, ICA PSA produces recurrent epistaxis; it is related instead to massive epistaxis, producing than symptoms that need prompt clinical evaluation.3 The diagnosis of post-traumatic PSA involves a definite history of head injury, delayed and serious repeated life-threatening epistaxis and radiological findings.4 CTA and subsequently angiography showed an irregular-mass-like contrast area protruding into the sphenoid sinus. Mortality rate in those cases is 30–50%, validating the therapeutic indication. Making a therapeutic decision regarding cavernous PSA of ICA is difficult. We believe that the optimal strategy is to control the vascular lesion with subsequent exams and to treat only if there is a life-threating bleeding. In advance to treatment, carotid occlusion test is necessary to demonstrate that the circle of Willis has good lateral circulation compensation function so that the patient can tolerate the occlusion, in case of unsuccessful treatment. Specifically, a detachable balloon is used to occlude the internal carotid artery on the affected side when the patient is in a conscious state, and controlled hypotension is performed in the
Figure 2. Axial (a), sagittal (b) and coronal (c) CTA scan shows left ICA PSA into the left sphenoidal sinus.
Figure 3. Digital subtraction angiography (DSA) of the left ICA PSA (a), detachment of FDS (b) and final control (c) showing correct FDS positioning and ICA patency.
Giorgianni et al.
327
Figure 4. Coronal (a) and sagittal (b) CTA control confirming PSA resolution.
meantime to decrease mean arterial pressure to 60–70 mmHg.5 In our case, we performed a left carotid axis manual compression during angiography. Ultimately, the utility of this test will be to understand the possibility of occluding ICA in case of unsatisfactory treatment or intraprocedural bleeding. Surgical treatments for these lesions have involved direct clipping, wrapping, trapping and carotid artery ligation. Surgery in these cases is technically demanding and carries a high risk of rupture during dissection and clipping. This is mainly due to the abnormal wall that forms the aneurysms following a subadventitial dissection of the vessel and the lack of a true neck.6 Endovascular treatment has several options.7,8 Direct obliteration of the ICA post-traumatic PSA with coils or balloons has been reported, but the lack of a true wall increases the risk of recanalisation and rupture. Extracranial or intracranial PSA of ICA has effectively been treated with endovascular stents, and several alternatives are currently available when a reconstructive technique is required. In the literature, several cases of treatment with uncovered stents and covered PTFE stents are described, but their limited flexibility is the main technical limitation.7 Celil et al. describe a case of cavernous carotid PSA treated with covered stent. After the treatment, the patient did not bled again and was discharged 3 days after the procedure.9 The covered stent may occlude the arterial branches, whereas porous stents can maintain the branches patency. Since there are few arterial branches originating from this segment of ICA, the covered stent is deemed to be more useful as compared with its use in other portions of the ICA that have major branches or perforating branches. Chen et al.,1 in a paper on diagnosis and treatment of traumatic internal carotid artery PSA, report 20 patients with direct occlusion of the artery by embolisation with detachable balloon and 11 patients treated with covered stent implantation to cover the arterial tear. RuizJuretschke et al. describe a case of endovascular treatment with overlapping self-expanding uncovered stent
in a massive epistaxis resulting from an intracavernous internal carotid artery traumatic PSA.8 Ko et al. describe another case of PSA treatment with balloon expandable covered stent with aneurysmal neck occlusion and preservation the parent artery.10 In our case we decided to use FDSs with small fenestrations at the PSA site in order to optimise immediate lesion thrombosis and to obtain reconstruction of intracavernous ICA. This FDS with nitinol wire braid and two helical strands maximises haemodynamic flow effect in the PSA, thanks to 64 filaments that make the device tighter. An immediate closure was achieved, without neurological complications. At the end of the procedure, we obtained vessel patency and minimum opacisation of a small neck portion. In conclusion, the FDS placement procedure is safe and quick in cases of massive epistaxis. The immediate exclusion of the PSA leads to arterial bleeding arrest and conduces to patient immediate clinical stabilisation. Detection and FDS application to ICA posttraumatic PSA can be considered a life-saving procedure.
Conclusion In addition to the devices described in the literature used frequently for endovascular treatment of epistaxis caused by ICA PSA bleeding, a FDS, which allows a sudden flow diversion with a rapid PSA thrombosis, may be used. In this way, we also ensure the reconstruction of the vessel in the traumatic injury segment. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest The authors declare no conflict of interest.
References 1. Chen D, Concus AP, Halbach BV, et al. Epistaxis originating from traumatic pseudoaneurysm of the internal
328
2.
3.
4.
5.
6.
carotid artery: diagnosis and endovascular therapy. Laryngoscope 1998; 108: 326–331. Auyeung KM, Lui WM, Chow LC, et al. Massive epistaxis related to peterous carotid artery pseudoaneurysm after radiation therapy: emergency treatment with covered stents in two cases. Am J Neuroradiol 2003; 24: 1449–1452. Asma A, Primuharsa Putra S and Saim L. Massive epistaxis secondary to pseudoaneurysm of internal carotid artery. Med J Malesia 2006; 61: 84–87. Chen G, Li J, Xu G, et al. Diagnosis and treatment of traumatic internal carotid artery pseudoaneurysm primarily manifested by repeated epistaxis. Turkish Neurosurg 2013; 23: 716–720. Goleas J, Mikhael MA, Paige ML, et al. Intracavernous carotid artery aneurysm presenting as recurrent epistaxis. Ann Otol Rhinol Laryngol 1991; 100: 577–579. Charbel FT, Gonzales-Portillo G, Hoffmann W, et al. Distal internal carotid artery pseudoaneurysms: technique and pitfalls of surgical management: two technical case reports. Neurosurgery 1999; 45: 643–648.
Interventional Neuroradiology 21(3) 7. Lehmann P, Saliou G, Page C, et al. Epistaxis revealing the rupture of a carotid aneurysm of the cavernous sinus extending into the sphenoid: treatment using an uncovered stent and coils. Review of literature. Eur Arch Otorhinolaryngol 2009; 266: 767–772. 8. Ruiz-Juretschke F, Castro E, Sierra OM, et al. Massive epistaxis resulting from an intracavernous internal carotid artery traumatic pseudoaneurysm: complete resolution with overlapping uncovered stents. Acta Neurochir 2009; 151: 1681–1684. 9. Celil G, Engin D, Orhan G, et al. Intractable epistaxis related to cavernous carotid artery pseudoaneurysm: treatment of a case with covered stent. Auris Nasus Larynx 2004; 31: 275–278. 10. Ko JK, Lee TH, Lee JI, et al. Endovascular treatment using graft-stent for pseudoaneurysm of the cavernous internal carotid artery. J Korean Neurosurg Soc 2011; 50: 48–50.
Flow-diverter stenting in post-traumatic pseudoaneurysm of cavernous internal carotid artery with epistaxis
Interventional Neuroradiology 2015, Vol. 21(3) 325–328 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1591019915582154 ine.sagepub.com
Andrea Giorgianni, Carlo Pellegrino, Renzo Minotto, Anna Mercuri, Fabio Baruzzi, Alfredo Cantoni, Larissa Nocchi Cardim and Luca Valvassori
Abstract This paper is a case report of a young patient after a major head trauma causing multiple skull base fractures. The trauma occasioned pseudoaneurysm (PSA) from intracavernous C4 segment of left internal carotid artery (ICA) protruding in the sphenoidal sinus. After two months, two episodes of massive epistaxis occurred. Consequently, the post-traumatic PSA was treated, after carotid occlusion test, with flow-diverter stent positioning. A computed tomography angiography study performed in the following days showed complete resolution of the post-traumatic PSA lesion and ICA patency.
Keywords Flow-diverter stenting, post-traumatic pseudoaneurysm, internal carotid artery
Introduction Massive epistaxis is a serious event in the clinical management of patients who present internal carotid artery (ICA) lesions after a trauma. Mortality rate is high. Endovascular treatment is a good alternative to conventional surgical treatments of these lesions. Several neurointerventional methods can be used for the therapy. In this case report, we describe a flow-diverter stent (FDS) treatment in a post-traumatic ICA pseudoaneurysm (PSA) bleeding.
Case report A 21-year-old male was admitted to our hospital after a major trauma, presenting severe head injury. The patient was intubated before being transferred to the hospital, with a Glasgow Coma Scale score of 3. The initial computed tomography (CT) scan revealed multiple facial fractures and a cranial base fracture affecting the left greater sphenoid wing and lateral ethmoid masses. Fracture of lateral left orbital wall, frontal and bilateral maxillary and sphenoidal sinus occurred (Figure 1). The CT angiography (CTA) showed an anterior wall focal dilatation of 19 mm of C4 intracavernous segment, leading to the diagnosis of a traumatic PSA of the left ICA with infero-medial development into the left sphenoidal sinus (Figure 2). The final digital subtraction angiography (DSA) confirmed a little neck of 20 mm diameter PSA.
Subsequent check with CTA two days after the trauma showed volume reduction of PSA with a maximum diameter of 13 mm. Approximately one month later, the patient was discharged and transferred to the rehabilitation centre. Two months after the trauma, two episodes of massive epistaxis occurred. The new CTA control confirmed the presence of PSA and it was decided to treat the vascular lesion. In the angiographic suite, the occlusion test was performed with manual compression of left carotid and showed not good compensation from right internal carotid artery. Distal superselective catheterisation of the left ICA was carried out and we proceeded to the FDS placement (4 18 mm, P64, Phenox, Bochum, Germany). First control documents carotid axis occlusion; thereby, is administered a 7 ml Abciximab (ReoPro) bolus. Final control after procedure showed correct FDS positioning (Figure 3) and ICA patency. It was recommended maintenance with subsequent infusion of 4.5 ml in 200 ml of saline solution for 12 hours. No intraprocedural complications occurred. The CTA control confirmed the PSA resolution and the stent patency (Figure 4).
Radiology Department, Ospedale di Circolo Varese, Varese, Italy Corresponding author: Carlo Pellegrino, Department of Radiology, Help Institution, Ospedale di Circolo Varese, Viale Borri 57, 21100 Varese, Italy. Email: [email protected]
326 Treatment with dual antiplatelet therapy for a month and a single aggregation for the following three months was proposed.
Discussion Trauma accounts for less than 5% of all severe cases of epistaxis.1
Figure 1. CT scan showing fracture of lateral left orbital wall, frontal and bilateral maxillary and sphenoidal sinus.
Interventional Neuroradiology 21(3) An intimal tear resulting from trauma can be explained by wall dissection, which consequently leads to decreased blood flow inside the PSA and intraluminal thrombus formation. PSA of the cavernous ICA can be a source of massive and life-threatening epistaxis and they are related to traumatic, congenital, mycotic and inflammatory causes.2 Rarely, ICA PSA produces recurrent epistaxis; it is related instead to massive epistaxis, producing than symptoms that need prompt clinical evaluation.3 The diagnosis of post-traumatic PSA involves a definite history of head injury, delayed and serious repeated life-threatening epistaxis and radiological findings.4 CTA and subsequently angiography showed an irregular-mass-like contrast area protruding into the sphenoid sinus. Mortality rate in those cases is 30–50%, validating the therapeutic indication. Making a therapeutic decision regarding cavernous PSA of ICA is difficult. We believe that the optimal strategy is to control the vascular lesion with subsequent exams and to treat only if there is a life-threating bleeding. In advance to treatment, carotid occlusion test is necessary to demonstrate that the circle of Willis has good lateral circulation compensation function so that the patient can tolerate the occlusion, in case of unsuccessful treatment. Specifically, a detachable balloon is used to occlude the internal carotid artery on the affected side when the patient is in a conscious state, and controlled hypotension is performed in the
Figure 2. Axial (a), sagittal (b) and coronal (c) CTA scan shows left ICA PSA into the left sphenoidal sinus.
Figure 3. Digital subtraction angiography (DSA) of the left ICA PSA (a), detachment of FDS (b) and final control (c) showing correct FDS positioning and ICA patency.
Giorgianni et al.
327
Figure 4. Coronal (a) and sagittal (b) CTA control confirming PSA resolution.
meantime to decrease mean arterial pressure to 60–70 mmHg.5 In our case, we performed a left carotid axis manual compression during angiography. Ultimately, the utility of this test will be to understand the possibility of occluding ICA in case of unsatisfactory treatment or intraprocedural bleeding. Surgical treatments for these lesions have involved direct clipping, wrapping, trapping and carotid artery ligation. Surgery in these cases is technically demanding and carries a high risk of rupture during dissection and clipping. This is mainly due to the abnormal wall that forms the aneurysms following a subadventitial dissection of the vessel and the lack of a true neck.6 Endovascular treatment has several options.7,8 Direct obliteration of the ICA post-traumatic PSA with coils or balloons has been reported, but the lack of a true wall increases the risk of recanalisation and rupture. Extracranial or intracranial PSA of ICA has effectively been treated with endovascular stents, and several alternatives are currently available when a reconstructive technique is required. In the literature, several cases of treatment with uncovered stents and covered PTFE stents are described, but their limited flexibility is the main technical limitation.7 Celil et al. describe a case of cavernous carotid PSA treated with covered stent. After the treatment, the patient did not bled again and was discharged 3 days after the procedure.9 The covered stent may occlude the arterial branches, whereas porous stents can maintain the branches patency. Since there are few arterial branches originating from this segment of ICA, the covered stent is deemed to be more useful as compared with its use in other portions of the ICA that have major branches or perforating branches. Chen et al.,1 in a paper on diagnosis and treatment of traumatic internal carotid artery PSA, report 20 patients with direct occlusion of the artery by embolisation with detachable balloon and 11 patients treated with covered stent implantation to cover the arterial tear. RuizJuretschke et al. describe a case of endovascular treatment with overlapping self-expanding uncovered stent
in a massive epistaxis resulting from an intracavernous internal carotid artery traumatic PSA.8 Ko et al. describe another case of PSA treatment with balloon expandable covered stent with aneurysmal neck occlusion and preservation the parent artery.10 In our case we decided to use FDSs with small fenestrations at the PSA site in order to optimise immediate lesion thrombosis and to obtain reconstruction of intracavernous ICA. This FDS with nitinol wire braid and two helical strands maximises haemodynamic flow effect in the PSA, thanks to 64 filaments that make the device tighter. An immediate closure was achieved, without neurological complications. At the end of the procedure, we obtained vessel patency and minimum opacisation of a small neck portion. In conclusion, the FDS placement procedure is safe and quick in cases of massive epistaxis. The immediate exclusion of the PSA leads to arterial bleeding arrest and conduces to patient immediate clinical stabilisation. Detection and FDS application to ICA posttraumatic PSA can be considered a life-saving procedure.
Conclusion In addition to the devices described in the literature used frequently for endovascular treatment of epistaxis caused by ICA PSA bleeding, a FDS, which allows a sudden flow diversion with a rapid PSA thrombosis, may be used. In this way, we also ensure the reconstruction of the vessel in the traumatic injury segment. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest The authors declare no conflict of interest.
References 1. Chen D, Concus AP, Halbach BV, et al. Epistaxis originating from traumatic pseudoaneurysm of the internal
328
2.
3.
4.
5.
6.
carotid artery: diagnosis and endovascular therapy. Laryngoscope 1998; 108: 326–331. Auyeung KM, Lui WM, Chow LC, et al. Massive epistaxis related to peterous carotid artery pseudoaneurysm after radiation therapy: emergency treatment with covered stents in two cases. Am J Neuroradiol 2003; 24: 1449–1452. Asma A, Primuharsa Putra S and Saim L. Massive epistaxis secondary to pseudoaneurysm of internal carotid artery. Med J Malesia 2006; 61: 84–87. Chen G, Li J, Xu G, et al. Diagnosis and treatment of traumatic internal carotid artery pseudoaneurysm primarily manifested by repeated epistaxis. Turkish Neurosurg 2013; 23: 716–720. Goleas J, Mikhael MA, Paige ML, et al. Intracavernous carotid artery aneurysm presenting as recurrent epistaxis. Ann Otol Rhinol Laryngol 1991; 100: 577–579. Charbel FT, Gonzales-Portillo G, Hoffmann W, et al. Distal internal carotid artery pseudoaneurysms: technique and pitfalls of surgical management: two technical case reports. Neurosurgery 1999; 45: 643–648.
Interventional Neuroradiology 21(3) 7. Lehmann P, Saliou G, Page C, et al. Epistaxis revealing the rupture of a carotid aneurysm of the cavernous sinus extending into the sphenoid: treatment using an uncovered stent and coils. Review of literature. Eur Arch Otorhinolaryngol 2009; 266: 767–772. 8. Ruiz-Juretschke F, Castro E, Sierra OM, et al. Massive epistaxis resulting from an intracavernous internal carotid artery traumatic pseudoaneurysm: complete resolution with overlapping uncovered stents. Acta Neurochir 2009; 151: 1681–1684. 9. Celil G, Engin D, Orhan G, et al. Intractable epistaxis related to cavernous carotid artery pseudoaneurysm: treatment of a case with covered stent. Auris Nasus Larynx 2004; 31: 275–278. 10. Ko JK, Lee TH, Lee JI, et al. Endovascular treatment using graft-stent for pseudoaneurysm of the cavernous internal carotid artery. J Korean Neurosurg Soc 2011; 50: 48–50.
