Endovascular Treatment of Radiation-Induced Petrous Internal Carotid Artery Aneurysm Presenting with Acute Haemorrhage. A Report of Two Cases

Abstract

Haemorrhage from rupture of petrous ICA aneurysm can be life threatening and emergency treatment is required. We report 2 cases of radiation-induced petrous internal carotid artery (ICA) aneurysm presenting with acute haemorrhage (epistaxis and otorrhagia) after radiotherapy (RT) for nasopharyngeal carcinoma (NPC). Both patients had a history of RT treatment for NPC. The first patient, a 54-year-old man, presented with sudden severe epistaxis and haemorrhagic shock. The second patient, a 35-year-old man, presented with episodes of severe otorrhagia. The first patient was immediately resuscitated. Obliteration of the aneurysm was performed by endovascular occlusion of the ICA with Guglielmi detachable coils and fibered platinum coils. For the second patient, the aneurysm was treated by deploying a self-expandable stent across the aneurysm neck. In an emergency situation, ruptured petrous ICA aneurysm can be treated with endovascular occlusion of the ICA with microcoils if there is a good collateral blood flow. Alternatively, the aneurysm can be treated by deployment of a stent, which can induce stasis and eventual thrombosis of the aneurysm.

Epistaxe de origem extranasal: desafio diagnóstico

“…When the occlusion test is positive we are given the option of ligating the carotid artery, in a combined procedure in which the vessel is ligated in its neck and intracranial segments. Surgical treatment poses high levels of risk, and in our patient's case -as her occlusion test was negative -the most adequate approach is endovascular 3,4,6 . Anti-platelet drugs can be used for 30 days to prevent intra-stent thrombosis.…”

Aneurysms of the petrous internal carotid artery: anatomy, origins, and treatment

“…43 A report exists of one rare case of a patient who had a giant petrous ICA aneurysm that presented as a cerebellopontine angle mass as a result of medial erosion of the petrous bone. 42 When these aneurysms spontaneously rupture, dramatic hemorrhage into the eustachian tube or middle ear can present as massive epistaxis 9,12,46,66 and/or otorrhagia. 9,12,21,24,32 This presentation is thought to occur in 25% of patients with petrous aneurysms, but the true incidence is not known.…”

“…8,9,12,18,32 There have even been cases of death from exsanguination. 2,8 Overall, these hemorrhages are always extracranial, and there have been no reported cases of intracranial hemorrhage from a ruptured petrous ICA aneurysm.…”

“…10,25,53 A final injection of contrast material through the guide catheter is used to confirm complete occlusion of the aneurysm and patency of the collateral circulation. 9,10,25 Others have used embolization coils instead of the second balloon. 12 Also, it is possible to perform an ICA occlusion exclusively with coil embolization.…”

“…12 Also, it is possible to perform an ICA occlusion exclusively with coil embolization. 9 Nevertheless, there is a risk of coil dehiscence out of the vessel into the ear canal, which can cause life-threatening hemorrhages, especially in patients with ruptured aneurysms. 9 Acute iatrogenic pseudoaneurysms located at the mesotympanum typically have no bone to encase the artery or pseudoaneurysm, thus precluding the option of coil embolization.…”