IMAGES FOR SURGEONS ANZJSurg.com
Massive epistaxis from sphenopalatine pseudoaneurysm 5 months after facial trauma A 64-year-old woman was presented to our emergency department with a 4-month history of recurrent, increasingly severe, posterior epistaxis. Upon presentation, she was actively bleeding and haemodynamically unstable. Investigations showed a precipitous fall in haemoglobin from 127 g/L to 69 g/L within the first few hours of admission. Her past history included a zygomatic complex fracture 5 months earlier following a fall (conservatively managed), severe aortic stenosis and chronic renal impairment. She had no history of bleeding diathesis and was not on any anticoagulant or antiplatelet medications. Initial resuscitation was achieved with large bore intravenous access and crystalloid replacement. Bloods were sent for urgent cross-match and to exclude coagulopathy. The nose was packed with one ConvaTec Kaltostat (ConvaTec UK, Flintshire, UK) rope dressing in each nostril with appropriate antistaphylococcal antibiotic coverage. Nasal packing initially controlled the epistaxis; however, rebleeding occurred en route to angiography despite the packs remaining in good position. Computed tomography (CT) demonstrated active contrast extravasation into the left maxillary antrum suggesting active arterial haemorrhage accessing the nasal airway via a posterior maxillary wall fracture (Fig. 1). Subsequent digital subtraction angiography (DSA) revealed extravasation from a 2-cm pseudoaneurysm arising from a distal branch of the sphenopalatine artery (Fig. 2). The proximal sphenopalatine artery was coiled with initial control of bleeding. Despite embolization, the patient remained haemodynamically unstable. A repeat DSA was performed and confirmed rebleeding secondary to collateralization from other branches of the ipsilateral sphenopalatine artery, with no evidence of cross-filling from the right carotid system (Fig. 3). The bleeding collateral branches were
successfully excluded using Pfizer Gelfoam (Pfizer Incorporated, New York, NY, USA) gelatine sponges and further coiling, achieving definitive haemostasis. Thence, the patient remained well with stable haemoglobin levels. She was discharged home a week after admission with full functional recovery and no subsequent complications were identified on follow-up. Intractable or severe epistaxis in the setting of previous trauma should prompt the reviewing doctor to consider pseudoaneurysm as the cause. A pseudoaneurysm evaginates from a full thickness injury through an arterial wall in continuum with the lumen, contained locally by surrounding tissues often associated with a haematoma.1 Most result from trauma or iatrogenic injury; infrequently, they may arise because of tumour infiltration, infection or vasculitis.2 Symptoms usually occur within 8 weeks of the initial injury, but can occur as late as 10 years after the insult.3 In our patient’s case, her symptoms of epistaxis began almost a month after her fall, reinforcing the need for a thorough and specific history. Various imaging modalities have been described in the investigation of vascular abnormalities such as pseudoaneurysms. These include non-invasive measures such as CT or CT angiography (CTA), Doppler ultrasonography and magnetic resonance angiography. Ultrasound is limited by the interposition of the facial skeleton4 and magnetic resonance imaging has a slow acquisition time in the setting of acute bleeding. CT imaging has the advantage of short acquisition time, wide accessibility, ever improving accuracy with modern machines, and the ability to pinpoint the affected vascular bed allowing subsequent targeted angiography. Pseudoaneurysms appear on CTA as enclosed areas of intermediate attenuation beside the donor vessel; they are often heterogeneous because of partial thrombosis and/or calcification.2
Fig. 1. Computed tomography scans with intravenous contrast of the facial bones and sinuses. (L) Axial soft tissue windows demonstrate a heterogeneous area of peripheral high attenuation surrounding an area of central low attenuation originating posterior to the posterolateral maxillary sinus wall fracture and extending into the maxillary sinus suggesting acute haemorrhage (arrow). (R) Axial bony windows demonstrate the posterolateral maxillary sinus wall fracture (medial to the haemorrhage arrow).
© 2014 Royal Australasian College of Surgeons
ANZ J Surg •• (2014) ••–••
2
Images for surgeons
Fig. 2. Digital subtraction angiography demonstrating the left external carotid artery (ECA) and internal maxillary artery (IMA) and its distal branches. Contrast extravasation is demonstrated from a branch of the sphenopalatine artery (SPA) resulting in a blush of contrast. The appearance is consistent with pseudoaneurysm (arrow). (L) Lateral view. (R) Antero-posterior view.
Fig. 3. Digital subtraction angiography demonstrating the catheter placed in the left internal maxillary artery (IMA). A series of coils are demonstrated in the distal IMA. The previous pseudoaneurysm and contrast extravasation demonstrated in Figure 2 have been excluded. However, extravasation distal to the coils is demonstrated secondary to local collateralization (arrow) (L) Lateral view. (R) Antero-posterior view.
Conversely, DSA allows real-time assessment of haemorrhage, exact identification of the donor artery and collateral vessels and allows simultaneous therapeutic intervention. However, DSA is not without risks, including stroke and blindness.2 Endovascular embolization typically results in definitive cessation of epistaxis without damage to adjacent tissues and avoidance of anaesthesia in unstable patients. Drawbacks include failure to identify the target vessel/s because of vasospasm,5 delayed haemorrhage because of collateralization,2 displacement of embolization material or thrombus2 into the non-target circulation and complications at the arterial puncture site. Our patient’s pseudoaneurysm was extremely challenging to treat using endovascular techniques because of the narrow calibre of the vessels involved and the abundance of collateral vessels. Access was technically challenging, embolization proximal and distal to the origin of the pseudoaneurysm could not be achieved, leading to rebleeding following collateralization. Aggressive management of pseudoaneurysmal bleeding is essential, especially in the setting of co-morbidities that affect the patient’s ability to compensate for severe haemorrhage. Conservative management such as packing of the nasopharynx is primarily used for airway protection and to temporize active bleeding prior to
definitive management. Although there is no universal protocol for the treatment of pseudoaneurysms of the external carotid circulation, endovascular management is the first-line therapy in the majority of cases, as it offers both diagnostic information and the best opportunity for targeted occlusion of the local feeding vessels, trapping the site of bleeding in most instances.2,6 In conclusion, pseudoaneurysms although rare, can cause lifethreatening epistaxis. They must be considered in any patient presenting with epistaxis with a history of significant facial trauma or in recurrent, haemodynamically significant, epistaxis. DSA remains the most accurate diagnostic, and potentially therapeutic, intervention. Continued epistaxis or haemodynamic instability after apparent successful endovascular treatment may portend rebleeding because of collateralization, particularly in the case of proximal occlusion (either surgical or endovascular) rather than trapping of the arterial segment.
References 1. Keeling A, McGrath F, Lee M. Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms. Cardiovasc. Intervent. Radiol. 2009; 32: 2–18.
© 2014 Royal Australasian College of Surgeons
Images for surgeons
2. Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005; 25: S173–89. 3. Campbell R. Sphenopalatine artery pseudoaneurysm after endoscopic sinus surgery: a case report and literature review. Ear Nose Throat J. 2012; 91: E4–11. 4. Clark R, Lew D, Giyanani VL. Gerlock A. False aneurysm complicating orthognathic surgery. J. Oral Maxillofac. Surg. 1987; 45: 57–9. 5. Raymond J, Hardy J, Czepko R. Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma: the role of angiography and endovascular treatment. AJNR Am. J. Neuroradiol. 1997; 18: 655–65. 6. Rudmik L, Smith T. Management of intractable spontaneous epistaxis. Am. J. Rhinol. Allergy 2012; 26: 55–60.
© 2014 Royal Australasian College of Surgeons
3
Peter Tao,* MBBS Deborah Amott,* FRACS Peter Mitchell,† RANZCR Tim A. Iseli,* FRACS *Otolaryngology, Head and Neck Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia and †Diagnostic and Interventional Radiology, Royal Melbourne Hospital, Parkville , Victoria, Australia doi: 10.1111/ans.12835
Massive epistaxis from sphenopalatine pseudoaneurysm 5 months after facial trauma A 64-year-old woman was presented to our emergency department with a 4-month history of recurrent, increasingly severe, posterior epistaxis. Upon presentation, she was actively bleeding and haemodynamically unstable. Investigations showed a precipitous fall in haemoglobin from 127 g/L to 69 g/L within the first few hours of admission. Her past history included a zygomatic complex fracture 5 months earlier following a fall (conservatively managed), severe aortic stenosis and chronic renal impairment. She had no history of bleeding diathesis and was not on any anticoagulant or antiplatelet medications. Initial resuscitation was achieved with large bore intravenous access and crystalloid replacement. Bloods were sent for urgent cross-match and to exclude coagulopathy. The nose was packed with one ConvaTec Kaltostat (ConvaTec UK, Flintshire, UK) rope dressing in each nostril with appropriate antistaphylococcal antibiotic coverage. Nasal packing initially controlled the epistaxis; however, rebleeding occurred en route to angiography despite the packs remaining in good position. Computed tomography (CT) demonstrated active contrast extravasation into the left maxillary antrum suggesting active arterial haemorrhage accessing the nasal airway via a posterior maxillary wall fracture (Fig. 1). Subsequent digital subtraction angiography (DSA) revealed extravasation from a 2-cm pseudoaneurysm arising from a distal branch of the sphenopalatine artery (Fig. 2). The proximal sphenopalatine artery was coiled with initial control of bleeding. Despite embolization, the patient remained haemodynamically unstable. A repeat DSA was performed and confirmed rebleeding secondary to collateralization from other branches of the ipsilateral sphenopalatine artery, with no evidence of cross-filling from the right carotid system (Fig. 3). The bleeding collateral branches were
successfully excluded using Pfizer Gelfoam (Pfizer Incorporated, New York, NY, USA) gelatine sponges and further coiling, achieving definitive haemostasis. Thence, the patient remained well with stable haemoglobin levels. She was discharged home a week after admission with full functional recovery and no subsequent complications were identified on follow-up. Intractable or severe epistaxis in the setting of previous trauma should prompt the reviewing doctor to consider pseudoaneurysm as the cause. A pseudoaneurysm evaginates from a full thickness injury through an arterial wall in continuum with the lumen, contained locally by surrounding tissues often associated with a haematoma.1 Most result from trauma or iatrogenic injury; infrequently, they may arise because of tumour infiltration, infection or vasculitis.2 Symptoms usually occur within 8 weeks of the initial injury, but can occur as late as 10 years after the insult.3 In our patient’s case, her symptoms of epistaxis began almost a month after her fall, reinforcing the need for a thorough and specific history. Various imaging modalities have been described in the investigation of vascular abnormalities such as pseudoaneurysms. These include non-invasive measures such as CT or CT angiography (CTA), Doppler ultrasonography and magnetic resonance angiography. Ultrasound is limited by the interposition of the facial skeleton4 and magnetic resonance imaging has a slow acquisition time in the setting of acute bleeding. CT imaging has the advantage of short acquisition time, wide accessibility, ever improving accuracy with modern machines, and the ability to pinpoint the affected vascular bed allowing subsequent targeted angiography. Pseudoaneurysms appear on CTA as enclosed areas of intermediate attenuation beside the donor vessel; they are often heterogeneous because of partial thrombosis and/or calcification.2
Fig. 1. Computed tomography scans with intravenous contrast of the facial bones and sinuses. (L) Axial soft tissue windows demonstrate a heterogeneous area of peripheral high attenuation surrounding an area of central low attenuation originating posterior to the posterolateral maxillary sinus wall fracture and extending into the maxillary sinus suggesting acute haemorrhage (arrow). (R) Axial bony windows demonstrate the posterolateral maxillary sinus wall fracture (medial to the haemorrhage arrow).
© 2014 Royal Australasian College of Surgeons
ANZ J Surg •• (2014) ••–••
2
Images for surgeons
Fig. 2. Digital subtraction angiography demonstrating the left external carotid artery (ECA) and internal maxillary artery (IMA) and its distal branches. Contrast extravasation is demonstrated from a branch of the sphenopalatine artery (SPA) resulting in a blush of contrast. The appearance is consistent with pseudoaneurysm (arrow). (L) Lateral view. (R) Antero-posterior view.
Fig. 3. Digital subtraction angiography demonstrating the catheter placed in the left internal maxillary artery (IMA). A series of coils are demonstrated in the distal IMA. The previous pseudoaneurysm and contrast extravasation demonstrated in Figure 2 have been excluded. However, extravasation distal to the coils is demonstrated secondary to local collateralization (arrow) (L) Lateral view. (R) Antero-posterior view.
Conversely, DSA allows real-time assessment of haemorrhage, exact identification of the donor artery and collateral vessels and allows simultaneous therapeutic intervention. However, DSA is not without risks, including stroke and blindness.2 Endovascular embolization typically results in definitive cessation of epistaxis without damage to adjacent tissues and avoidance of anaesthesia in unstable patients. Drawbacks include failure to identify the target vessel/s because of vasospasm,5 delayed haemorrhage because of collateralization,2 displacement of embolization material or thrombus2 into the non-target circulation and complications at the arterial puncture site. Our patient’s pseudoaneurysm was extremely challenging to treat using endovascular techniques because of the narrow calibre of the vessels involved and the abundance of collateral vessels. Access was technically challenging, embolization proximal and distal to the origin of the pseudoaneurysm could not be achieved, leading to rebleeding following collateralization. Aggressive management of pseudoaneurysmal bleeding is essential, especially in the setting of co-morbidities that affect the patient’s ability to compensate for severe haemorrhage. Conservative management such as packing of the nasopharynx is primarily used for airway protection and to temporize active bleeding prior to
definitive management. Although there is no universal protocol for the treatment of pseudoaneurysms of the external carotid circulation, endovascular management is the first-line therapy in the majority of cases, as it offers both diagnostic information and the best opportunity for targeted occlusion of the local feeding vessels, trapping the site of bleeding in most instances.2,6 In conclusion, pseudoaneurysms although rare, can cause lifethreatening epistaxis. They must be considered in any patient presenting with epistaxis with a history of significant facial trauma or in recurrent, haemodynamically significant, epistaxis. DSA remains the most accurate diagnostic, and potentially therapeutic, intervention. Continued epistaxis or haemodynamic instability after apparent successful endovascular treatment may portend rebleeding because of collateralization, particularly in the case of proximal occlusion (either surgical or endovascular) rather than trapping of the arterial segment.
References 1. Keeling A, McGrath F, Lee M. Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms. Cardiovasc. Intervent. Radiol. 2009; 32: 2–18.
© 2014 Royal Australasian College of Surgeons
Images for surgeons
2. Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005; 25: S173–89. 3. Campbell R. Sphenopalatine artery pseudoaneurysm after endoscopic sinus surgery: a case report and literature review. Ear Nose Throat J. 2012; 91: E4–11. 4. Clark R, Lew D, Giyanani VL. Gerlock A. False aneurysm complicating orthognathic surgery. J. Oral Maxillofac. Surg. 1987; 45: 57–9. 5. Raymond J, Hardy J, Czepko R. Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma: the role of angiography and endovascular treatment. AJNR Am. J. Neuroradiol. 1997; 18: 655–65. 6. Rudmik L, Smith T. Management of intractable spontaneous epistaxis. Am. J. Rhinol. Allergy 2012; 26: 55–60.
© 2014 Royal Australasian College of Surgeons
3
Peter Tao,* MBBS Deborah Amott,* FRACS Peter Mitchell,† RANZCR Tim A. Iseli,* FRACS *Otolaryngology, Head and Neck Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia and †Diagnostic and Interventional Radiology, Royal Melbourne Hospital, Parkville , Victoria, Australia doi: 10.1111/ans.12835
