Turkish Neurosurgenj 12: 128 - 134, 2002 5e11cer: Posttrallmatic Damage To The Illte1"lltli Carotid Arterlf

Posttraumatic Damage To The Internal Carotid Artery:Pseudo aneurysm Presenting With Epistaxis And

Direct Carotid Cavernous Fistula

internal KarotisVe Epistaksis

Arter Yaralanmasl: Direkt Karotiko-Kavernoz Fistiilhe Kendini Gosteren Psodonaevrizma Olu~umu

SERRA SENCER, OZENC MiNARECi, ARZU POYANLI

Istanbul University, Istanbul School of Medicine, Department of Radiology (55, OM, AP)

Received: 19.6.2001 ¢::> Accepted: 13.9.2001

Abstract: Three cases of posttraumatic internal carotidartery pseudoaneurysms presenting with epistaxis andassociated direct carotid cavernous fistulae in two of the

patients are presented. The rare association of the two typesof posttraumatic internal carotid artery damage as well asthe method and outcome of endovascular therapyperformed in these cases will be reported.

Key words: Pseudoaneurysm- epistaxis- direct carotidcavernous fistula

INTRODUCTION

Posttraumatic pseudoaneurysms of the internalcarotid artery (rCA) presenting with epistaxis andhigh flow carotid cavernous fistulas (CCF) due totraumatic laceration in the cavernous segment of ICAare rare sequelae of head trauma. Rapid diagnosisand immediate endovascular or surgical treatmentis very important in reducing morbidity andmortality in both entities (4,8,9). Three cases withtraumatic pseudoaneurysms of ICA presenting with

128

Ozet: AmnF Psodoanevrizma ve direkt karotikokavernozfishil olu~umu internal karotis arter travmaSI SOllllCUolll~an iki nadir yaralanma tipidir.Olgll SI/nl/lltll: Bu c;ah~mada tiC;olgllda epistaksis ilekendini gosteren internal karotis arter psodoanevrizmaslve olgulardan ikisinde e~lik eden direkt karotikokavernozfishil sunulmaktadlr.SOnl/{:: internal karotis arterde olll~an iki nadir yaralanmabic;imi ve bu olgulardaki endovaskUler tedavi yontem vesonuc;lan sunulmaktadlr.

Anahtar Kelimeler: Psodoanevrizma, epistaksis, direkkarotiko-kavernoz fisml

epitaxis, two of which were associated with directCCF are presented. The rare association of the twotypes of injury, clinical course and outcome ofendovascular therapy in these cases will be reported.

CASE REPORTS

Case 122-year-old male patient presented with

progressive vision loss, chemosis and proptosis inthe left eye. He had suffered a traffic accident six

Turkish Neurosurgery 12: 128 - 134, 2002

months ago, when he was hospitalized for headtrauma. There was total loss of vision in the righteye due to transection of the optic nerve and multiplefractures in the anterior and middle skull base. There

was one episode of massive epistaxis one week aftertrauma, which had been controlled with posteriornasal packing.

Cranial CT scan performed on the presentadmission showed enlargement of the left cavernoussinus, exophthalmus of the left globe and fractures

Sel/cer: Post/raullla/ic Damage To The II//emal Carotid Arlen!

in the left orbit and sphenoid sinus waJls. Thesphenoid sinus was filled with dense material.

During cerebral angiography, a direct carotidcavernous fistula supplied by a large tear in the C3­C4 segments of the left ICA was detected. The leftcavernous sinus was extremely distended becauseof the high flow fistula draining by way of theipsilateral ophthalmic veins and contralateralcavernous sinus. Two pseudoaneurysmal sacsextending into the left sphenoid sinus at the site of

figure 'Ia: Figure 'Ia (Case n Midarterial phase image oflateral left lCA injection in a young male withepistaxis and proptosis shows a direct carotidcavernous fistula and pseudoaneurysmsextending into the sphenoid sinus.

Figure 'Ib: After balloon embolization of the extremelydistended cavernous sinus, fistulous flow and

pseudoaneurysmal opacification are reducedwith diminished steal in the intracranial flow.

Figure 'Ie: One week later, although some of the b<1IIL'(lnShave deflated, the fistulous flow is diminished

further; the pseudoaneurysms are no longervisualized.

Figure 'Id: Follow up cerebral angiogram performed onemonth later reveals total fistula thrombosis with

some thinning in the supraophthalmic segmentof lCA, and a pseudoaneurysm in the cavernousportion of the artery.

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Turkish Neurosurgery 12: 128 - 134, 2002

the fracture were also detected (Figure la). Significantdiminution of intracranial flow was observed due to

the steal of the high flow fistula with collateral flowfrom the contralateral ICA and leptomeningealvessels. Endovascular balloon occlusion of the fistulawas planned in order to restore intracranial flow inthe left cerebral hemisphere and to preserve visionin the left eye by reversing orbital venoushypertension. Arrest of flow in the pseudoaneurysmswas another goal of therapy taking into considerationthe episode of massive epistaxis.

Multiple detachable balloons were dislodged inthe cavernous sinus on the venous side of the fistulausing transarterial access. Upon detection of increasein the intracranial flow and some diminution of

venous reflux into the ophthalmic veins, theprocedure was terminated (Figure Ib). The patientwas followed closely for one week. During thatperiod, exophthalmus and congestion in the left eyeregressed and visual acuity improved. A repeatcerebral angiography at the end of the first weekshowed that some of the balloons had deflated;however, the fistula flow was significantly slowerand pseudoaneurysms were not visualized (Figurelc). No further endovascular therapy wasundertaken upon interpretation of the findings asprogressive fistula thrombosis.

A control angiogram performed one month latershowed some displacement and irregularity in thecavernous segment of the left internal carotid arteryresulting from the enlarged and thrombosedcavernous sinus. There was fotal restoration ofintracranial flow in the ipsilateral hemisphere andthe fistula and pseudoaneurysms were obliterated(Figure Id). During the last follow up visit in the fifthyear of endovascular therapy, the ophthalmicfindings had totally resolved. There were no newneurologic deficits or new episodes of epistaxis.

Case 2:

27 year-old-male patient was admitted withmassive epistaxis, which was controlled withposterior nasal packing. History revealed a motorvehicle accident one year before admission, whichhad resulted in multiple fractures in the righttemporal skull and lateral wall of the left sphenoidsinus (2a). He had been neurologically stable at thetime but suffered an episode of moderate epistaxisone week after trauma, which had spontaneouslyresolved. The last bout of epistaxis one day beforereferral to our institution was pulsatile and severecausing a drop of 3 gr. in haemoglobin level. The

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Sencer: Posttmll/nntic Dnulf/gc To Tile Illfemnl Cnn>t/lt Artery

patient was referred to our institution forangiography and endovascular therapy of epistaxis.

During cerebral angiography, a largepseudoaneurysm originating from the CI-2 segmentsof the cavernous portion of left ICA and extendingcaudally into the left sphenoid sinus was detected(2b and c). Due to the relatively wide neck andpresumably weak walls of the sac, no attempt wasmade to occlude the pseudoaneurysm. Balloonocclusion of the left ICA was performed. Adetachable balloon was inflated in the cavernous

segment adjacent to the neck of the aneurysmoccluding the left ICA. Nonfilling of the fistula wasangiographically observed. After a test occlusionlasting 45 minutes, the balloon was detached upondetection of full clinical and angiographic tolerancefor left ICA occlusion (Figure 2d). Two safety balloonswere detached in the petrous and cervical segmentsof the left ICA. There were no complications in theimmediate postoperative period. In the sixth-month­follow up, the patient appeared well with noneurologic deficit or history of recurrent epistaxis.

Case 3:

28 year-old male patient was admitted withprogressive proptosis and congestion in the left eye,which had started two months ago. He alsocomplained of blurred vision. On examination, abruit was audible over the left globe. He had sufferedtrauma by falling from a height one year ago whenhe was hospitalized with no major neurologic deficit

Figure 2a (Case 2): CT in bone algorithm shows fracturesin the right side of the skull base (not shown) andleft sphenoid sinus in a young male patientadmitted with massive epistaxis.

Turkish Neurosurgery 12: 128 - 134, 2002 Selleer: Po!'ttrnllIllatie Damage To Tile llltemal Carotid Artery

Figure 2b and c: Lateral left vertebral artery injection with simultaneous compression of the ipsilateral common carotidartery demonstrates a pseudoaneurysm originating from the distal cavernous segment of the lCA and extendinginto the sphenoid sinus (b). There is contrast stagnation in the aneurysmal sac (c).

,.

Figure 2d: After balloon occlusion of the left lCA at thepoint of the tear, right lCA injection in theanteroposterior projection shows total obliterationof the pseudoaneurysm with symmetricangiographic perfusion in both hemispheres.

except for a temporary left sixth cranial nerve palsy.Imaging performed at the time is inaccessible,however, basilar skull fractures have been reported.Medical history also revealed two episodes ofmassive epistaxis four and six weeks after trauma,which were controlled with posterior packing.

Cerebral angiography revealed a direct carotidcavernous fistula supplied by a tear in the distal

cavernous segment of the left ICA. Apseudoaneurysm with a relatively narrow neckextending into the left sphenoid sinus was alsopresent (Figure 3a). A detachable balloon was placedon the venous side of the fistula via transarterial

approach, inflated and detached with total occlusionof the fistula as well as the pseudoaneurysm (Figure3b). Repeat cerebral angiography was performed thenext day because of recurrent eye findings associatedwith the fistula. On angiography, it was observedthat the balloon had deflated and the fistula has

recurred. A total of five appropriate size electricallydetachable microcoils and a detachable balloon werethen placed in the cavernous sinus on the venous sideof the fistula. Upon detection of residual fistulousflow in the control ICA injections, balloon occlusionof the left ICA was performed with a detachableballoon placed inside the parent artery at the pointof the tear (Figure 3c and d). The patient wasdischarged a few days later with no neurologicdeficit. During the first and sixth month follow up,the eye signs had totally resolved and there were nonew episodes of epistaxis or neurological problems.

DISCUSSION

Rupture of aneurysms in the cavernous segmentof the internal carotid artery may result in lifethreatening epistaxis. Aneurysms may be traumaticpseudoaneurysms, or real saccular aneurysms;however, there are also reports of tuberculosisinfection, transsphenoidal surgery and radiotherapyresulting in pesudoaneurysm formation in the ICA

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Turkish Neurosurgery 12: 128 - 134, 2002 Sel/cer: Posttraumntic Dmnngc To The II/terl/nl Cnrotid Arlenl

Figure 3a: Figure 3a (Case 3): Left lateral lCA injection ofa young male with similar symptoms with thefirst case shows a direct carotid cavernous fistulaand pseudoaneurysm extending into thesphenoid sinus.

Figure 3b: The fistula and pseudoaneurys111 have beentotally occluded with a detachable balloondislodged on the venous side via transarterialapproach. There is a slight impression of theballoon in the anterior wall of the distal

cavernous lCA segment.

leading to massive epistaxis (3,6,10,15). In this smallseries of patients, all aneurysms were traumaticpseudoaneurysms and first episode of epistaxisoccurred one to four weeks after trauma. The latencyperiod of epistaxis in patients with leApseudoaneurysm following traumatic insult isvariable and mortality has been shown to be as highas 30 % (4). No mortality related to epistaxis or

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Figure 3c:The fistula has relapsed due to balloon migrationin the control angiogram performed on the nextday upon recurrence of symptoms.

Figure 3d: Left vertebral artery injection after parent arteryocclusion with detachable balloons and

electrically detachable coils shows total fistulaocclusion and hemispheric perfusion from theposterior communicating artery.

endovascular therapy has been encountered in thisstudy.

The typical clinical presentation in patients \vithtraumatic pseudoaneurysm of the internal carotidartery is history of head injury, monocular blindnessand life threatening epistaxis, also referred to asMauer's triad (9). History of head injury and epistaxis

Turkish Neurosurgery 12: 128 - 134, 2002

of varying severity was present in all of our threepatients and monocular blindness was present in one(Case 1) due to transection of the optic nerve duringcraniofacial injury.

In two of the patients (Cases 1 and 3) signs andsymptoms of carotid cavernous fistula, another rarebut potentially devastating sequel of head traumawith skull base fractures, dominated the clinicalpicture. Classically, a direct carotid cavernous fistulacan be defined as a high flow communicationbetween the cavernous internal carotid artery andthe cavernous sinus and may most commonly be theresult of traumatic laceration of the artery or therupture of a saccular aneurysm into the cavernoussinus. The signs and symptoms, which may also bedelayed similar to the rupture of traumatic ICApseudoaneurysm, are headache, orbital pain,diplopia, exophthalmus, pulsatile bruit and visualloss. Transvenous or transarterial embolization of thefistula and endovascular balloon occlusion of the ICA

are the possible endovascular treatment modalities(5,14).

The association of traumatic pseudonaeurysmof the internal carotid artery and direct carotidcavernous fistula is rare. Millman and Giddingsreported one case presenting with major epistaxisrelated to ICA pseudoaneurysm and signs andsymptoms of carotid cavernous fistula onexamination. The management of the lesions is notdiscussed in their report (12). In their series of fivepatients with traumatic intracavernous aneurysmspresenting with massive epistaxis, Liu and colleaguesreported one case with accompanying direct carotidcavernous fistula. The patient was managedsurgically with trapping of the internal carotid arteryand muscle embolization of the fistula with favorable

postoperative course (11). One earlier report of theassociation of epistaxis and carotid cavernous fistulacame from Wilson et aI, in 1966 (16).

Rapid diagnosis and immediate managementof epistaxis related to traumatic ICApseudo aneurysms are crucial in reducing the highmortality. Diagnosis may be delayed due to otherproblems resulting from head injury and theequivocal nature of the epistaxis, which is commonlydelayed and rarely severe during the initial attacks.Surgical repair of the aneurysm and trapping orligation of the ICA as well as endovascular occlusionof the ICA and selective obliteration of the fistula via

trans arterial or transvenous route (without parent

Sel/cer: Posllraumalic Damage To The II/Iemal (Il/,atid Arlenr

artery sacrifice) has been successfully performed inthe management of traumatic pseudoaneurysms ofthe internal carotid artery (4, 7, la, 11). In our patientsendovascular treatment has succeeded in thedefinitive treatment of epistaxis and the symptomhas not recurred during a follow up period of sixmonths to five years. Endovascular occlusion of thepseudoaneurysm has not been an attractive optiondue to the danger of rupture or uncontrollablebleeding resulting from damage to the weak fibrouswalls of the aneurysm.

In this series, one patient with traumaticaneurysm and carotid cavernous fistula (Case 1) hasbeen managed with transarterial balloonembolization of the fistula, which also resulted inocclusion of the pseudoaneurysm. The other patientwith the same angiographic findings (Case 3) hasbeen managed with balloon occlusion of the internalcarotid artery with successful closure of the fistulaand the pseudoaneurysm. The indication ofendovascular therapy in both cases was preventionof stroke and recurrent bouts of epistaxis as well asrestoration and salvage of vision endangered byorbital venous congestion inflicted by the high flowfistula. Successful treatment of posttraumaticpseudoaneurysms of the carotid artery withendoluminal stenting and transstent coiling has beenreported in recent literature (1, 2, 13).

In this small series of patients with traumaticpseudoaneurysm of the ICA and direct carotidcavernous fistulas, catheter angiography andendovascular therapy has succeeded in definitivediagnosis and treatment. Our results together withothers' from literature strongly suggest thatendovascular therapy should be the treatment ofchoice in both lesions.

CONCLUSION

This study reports three cases of traumaticpseudoaneurysms of the internal carotid arteryaccompanied by direct carotid cavernous fistula intwo patients. Massive epistaxis and the mainlyophthalmic signs and symptoms of the high flowfistula should prompt immediate angiographicevaluation. Although rare as sequelae of head traumaand even rarer when in association, the authorssuggest that the results of this study and data fromliterature imply that endovascular embolization isthe treatment of choice in these potentiallydevastating entities.

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Tllrkish Nellrosllrgery 12: 128 - 134, 2002

Correspondence: Dr. Serra Sencer

Atakoy, 9.KlslmA4-B, D: 81

34750, istanbul - TurkeyFax: 90 212 533 13 80 - 631 0728

Phone: 90 212 560 93 82 - 533 13 80

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