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Nontraumatic and postirradiated intracavernous carotid hemorrhage:
an unusual case of epistaxis and review of the literature
Jing-Jing Wang, MDa, Yong Wang, MDb, Po-Hung Chang, MDc,Ta-Jen Lee, MDc, De-Hui Wang, MDa,
aDepartment of Otolaryngology-Head and Neck Surgery, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College,
Fudan University, Shanghai, PR ChinabDepartment of Neurosurgery, Jiao Tong University, Shanghai, PR China
cDivision of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
Received 9 August 2009
Abstract Intracavernous carotid hemorrhage is a rare cause of epistaxis. We present a case of epistaxis caused
by postradiotherapy and nontraumatic cavernous internal carotid artery (ICA) hemorrhage. An 80-
year-old man was admitted to our hospital with a one week history of recurrent left-sided epistaxis
and a past history of radiotherapy after radical maxillectomy. Emergent angiography revealed a leak
in the cavernous segment of the ICA and subsequent detachable balloon occlusion embolization of
the left internal carotid artery was performed without sequelae. We conclude that carotid artery
hemorrhage must be considered in the differential diagnosis of profuse and recurrent epistaxis,
especially for patients after craniofacial radiotherapy. ICA embolization is the definitive treatment
provided cross circulation is adequate.
2011 Elsevier Inc. All rights reserved.
1. Introduction
Epistaxis is the most common emergency in otorhinolar-
yngology [1]. It may result from a multitude of causes, both
local and systemic. Most cases are due to bleeding from the
anterior nasal septum and are easily managed with local
measures. Posterior epistaxis is more severe, with a distinct
source of bleeding often difficult to localize. Common
etiologic factors include mucosal dryness, digital trauma,
nasal septal deviation, anticoagulation drug in use, and
hypertension. Uncommon etiologic factor for epistaxis is
trauma that, together with vascular abnormalities, accounts
for fewer than 5% of severe cases [2-4].
Rupture of postirradiated great vessels is rare. Fewer than
10 cases have been reported in the English literature [5]. The
most common presentation for nontraumatic and postirra-
diated cavernous internal carotid artery (ICA) rupture is
pseudoaneurysm. Several cases in the literature report this
complication of craniofacial radiotherapy, all in those with
nasopharyngeal carcinoma [6-8].
Patients with epistaxis who fail initial conservative
therapy require endoscopic cautery, surgical ligation, or
transarterial embolization of the nasal cavity vascular supply.
Embolization is primarily targeted at the branches arising
from the internal maxillary artery [4]. Today, embolization is
an accepted treatment of anterior and posterior epistaxis,
where available. This report illustrates a case of epistaxis
caused by a radiation-induced and nontraumatic ICA
hemorrhage without presenting pseudoaneurysm.
2. Case report
An 80-year-old man was admitted in to our hospital with
a 1-week history of recurrent left-sided epistaxis. Eleven
years ago, the patient underwent a radical maxillectomy for
squamous cell carcinoma of the maxillary antrum. Postop-
erative radiotherapy had been given according to the
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American Journal of OtolaryngologyHead and Neck Medicine and Surgery 32 (2011) 162164www.elsevier.com/locate/amjoto
Corresponding author. Department of Otolaryngology-Head and Neck
Surgery, Eye, Ear, Nose and Throat Hospital, Shanghai Medical College,
Fudan University, 83 Fenyang Road, Shanghai 200031, PR China. Tel.: +86
21 64 377 134 388; fax: +86 21 64 377 151.
E-mail address: [email protected] (D.-H. Wang).
0196-0709/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjoto.2009.10.006
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regulation dose. Two years ago, he received a course of
knife therapy for metastasis in the left temporal lobe of
the brain.
The initial physical examination showed unremarkable.
Contrast-enhanced computed tomography and magnetic
resonance imaging (MRI) scans revealed no hemorrhagic
focus. Interestingly, the MRI scan revealed that the lateral
wall of the sphenoid sinus was quite close to the ICA
(Fig. 1A). A review of his previous films revealed that only a
thin layer of soft tissue separated the ICA from the lateral
wall of the sphenoid sinus (Fig. 1B).
During the endoscopic operation, osteonecrosis was
found on the anterior skull base with a defect area of 2
3 cm2. Cerebral dura mater was exposed with obvious
pulsation. The operation ended by anterior and posterior
packing with yarn.
The patient was transferred to Shanghai Renji Hospital
Neurosurgery Department, where an emergent angiogram
revealed much leakage in the cavernous segment of the ICA.
After a successful balloon occlusion test with hypotensive
challenge, detachable balloon occlusion embolization of the
left ICA was performed. Two balloons were placed,
respectively, on the proximal and distal ends of that segment.The patient had no neurologic deficit as a result of the
procedure. A follow-up at 6 months demonstrated no
symptoms of epistaxis or neurologic deficit.
3. Discussion
Epistaxis, the most common emergency in otorhinolaryn-
gology [1], results from a multitude of causes, both local and
systemic. Intracavernous carotid hemorrhage is a rare cause
of epistaxis. The most common presentation for nontraumatic
and postirradiated cavernous ICA rupture is pseudoaneurysm
[6-8]. Our patient was a very unusual case of ICA hemorrhage
with leakage of the intracavernous carotid artery but no
pseudoaneurysm. Pseudoaneurysm formation results from
ICA hemorrhage or hematoma forming a peripheral fibrous
wall. Weakening and enlargement from continuous pulsatile
forces can result in breakdown of the fibrous wall with
eventual rupture. In cases of significant trauma to the anterior
cranial base, pseudoaneurysms can occur in the cavernous
segment of the ICA. The initial clinical presentation may be
massive epistaxis resulting from disruption through the
sphenoid sinus wall [3].
However, in this case with previous maxillectomy,
radiotherapy, and knife therapy, osteoradionecroses ofboth the maxilla and the skull base were found during
endoscopy. The base of the cavernous sinus had only a thin
layer of soft tissue separating the lateral wall of the sphenoid
sinus from the ICA. The hemorrhage from the ICA directly
entered the sphenoid sinus through the cavernous sinus,
making a cavernous internal carotid pseudoaneurysm
impossible.
Osteoradionecroses of the maxilla and base of skull are
rare phenomena, usually seen after combined therapies for
malignancies of the maxillary sinus. Although the mandible
is most commonly affected by osteoradionecroses, the
Fig. 1. Anteroposterior-view magnetic resonance imaging of ICA segment.
(A) A T2-weighted MRI reveals left nasal cavity was packed with yarn and
the lateral wall of the sphenoid sinus was close to the ICA (arrowhead). (B)
A T1-weighted MRI revealed only a thin layer of soft tissue between the
lateral wall of the sphenoid sinus and the ICA (arrowhead).
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maxilla and skull base may also be affected when
preoperative or postoperative radiotherapy is combined
with surgery. Contributing factors may include high
radiation dosage delivered to the treatment volume, loss of
tissue protective effects due to surgery, decreased vascularity
caused by surgery and radiation, and proximity of a
contaminated field. Onset of symptoms may vary and may
include pain, trismus, and purulent discharge. However, in
this case, only a headache was noted. The best diagnostic
modality remains the history and physical examination
because the area is readily accessible. Computed tomogra-
phy scans may help in diagnosis and treatment planning [9].
Lam et al [6] reported 4 cases of ICA pseudoaneurysm
rupture after radiation-induced temporal bone osteoradione-
crosis. They concluded that skull base osteoradionecrosis
with bleeding from the ICA is a potentially fatal complica-
tion of irradiation. Angiography was the mainstay of
diagnosis with embolization of the aneurysm and emboliza-
tion or ligation of the ICA as management options.
Embolization for epistaxis was first performed bySokoloff[10] in 1974. Since then, embolization has become
an accepted treatment of posterior epistaxis, where available
[11]. ICA occlusion is the definitive treatment in the ICA
hemorrhage, provided cross-circulation is adequate. Never-
theless, ligation or embolization occlusion of the ICA runs a
high risk of a cerebrovascular accident and mortality [6].
Acute ischemic infarcts causing death may occur once the
ICA is ligated or embolized. The likelihood of cerebral
complications depends on the adequacy of the collateral
blood supply. In this case, the successful balloon occlusion
test with hypotensive challenge minimized the likelihood of
inadequate cross-circulation. To our knowledge, old age hasnot been reported as a contraindication in performing ICA
embolization, and the procedure was successfully per-
formed in this 80-year-old man. In case of failure of this
procedure, ligation of ICA and extraintracranial bypass
surgery would have been considered, although the potential
risk and complication had to be fully discussed with the
patient and family.
Multidisciplinary collaboration is very important in
treating epistaxis. Epistaxis is usually first dealt with in the
ENT department, but ICA hemorrhage will necessitate
collaboration of an otorhinolaryngologist, neurosurgeon,
radiologist, anesthesiologist, nurses, and other team mem-
bers. Carotid angiography must be examined cautiously to
investigate for slight ICA leakage. ICA embolization is the
definitive treatment provided cross-circulation is adequate.
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