Figure 1
Paranasal sinuses CT
A rare cause of epistaxis: non-traumatic cavernous carotid aneurysm
SectionHead & neck imaging
Case TypeClinical Cases
Authors
Soares P1, Branco G1,2, Jordão C1, Graça J1, Evangelista P1, Silva D1.
1- Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
2- Hospital CUF Infante Santo, Lisbon, Portugal
Connected authors
41 years, female
Clinical History
41-year-old female patient with severe recurrent spontaneous epistaxis, with no prior history of head injury or relevant co-morbidity, leading to a haemoglobin count of 5.3g/dl.
Imaging Findings
A 41-year-old female patient presented at the Emergency Room with severe spontaneous epistaxis, with no prior history of head injury or relevant co-morbidity. The epistaxis, temporarily controlled, recurred four times, dropping the haemoglobin count to 5.3g/dl. After haemodynamic stabilisation she was transferred to our institution, where paranasal sinuses CT revealed opacification of the right sphenoid sinus and a small bone defect of its supero-lateral wall (Fig. 1).
CT-angiography revealed an aneurysm of the right cavernous internal carotid artery with intra-sphenoid extension through the bone defect, measuring 4.5 mm (dome) x 3 mm (neck) (Fig. 2). No other intra-cranial aneurysms where detected.
Digital subtraction angiography (DSA) confirmed the above findings (Fig. 3).
CT-angiography revealed an aneurysm of the right cavernous internal carotid artery with intra-sphenoid extension through the bone defect, measuring 4.5 mm (dome) x 3 mm (neck) (Fig. 2). No other intra-cranial aneurysms where detected.
Digital subtraction angiography (DSA) confirmed the above findings (Fig. 3).
Discussion
Epistaxis due to cavernous carotid pseudo-aneurysms is well documented. Usually it is associated with traumatic head injury, namely skull base fractures [1]. Epistaxis tends to occur weeks after the injury, although cases with a larger time gap have been reported [2].
True cavernous carotid aneurysms presenting with epistaxis, on the other hand, are extremely rare, although potentially fatal [3]. A recent review of the literature revealed a total of 36 patients with epistaxis from true cavernous carotid aneurysms [4].
Cavernous carotid aneurysms occur spontaneously in the absence of trauma but in the presence of a pre-existing bone defect of the wall of the sphenoid sinus [5], as can be seen in our case.
Traditionally treatment involved ICA occlusion (ligation or balloon), sphenoid packing or when possible aneurysm clipping. More recently, an approach sparing the carotid has been preferred, with successful aneurysm coiling especially in conjunction with stenting.
In this case treatment was attempted solely with high density braided stents. Two stents were successively placed in the cavernous ICA, in two separate procedures; however due to epistaxis recurrence after each session anti-platelet therapy was stopped and asymptomatic obliteration of the ICA occurred. Adequate intracranial perfusion was maintained through the anterior and posterior communicating arteries and the patient was discharged asymptomatic.
Although extremely rare, true carotid aneurysms with sphenoid extension may cause epistaxis, reason why this entity should be included in the differential diagnosis of one of the most common emergencies encountered by otolaryngologists.
True cavernous carotid aneurysms presenting with epistaxis, on the other hand, are extremely rare, although potentially fatal [3]. A recent review of the literature revealed a total of 36 patients with epistaxis from true cavernous carotid aneurysms [4].
Cavernous carotid aneurysms occur spontaneously in the absence of trauma but in the presence of a pre-existing bone defect of the wall of the sphenoid sinus [5], as can be seen in our case.
Traditionally treatment involved ICA occlusion (ligation or balloon), sphenoid packing or when possible aneurysm clipping. More recently, an approach sparing the carotid has been preferred, with successful aneurysm coiling especially in conjunction with stenting.
In this case treatment was attempted solely with high density braided stents. Two stents were successively placed in the cavernous ICA, in two separate procedures; however due to epistaxis recurrence after each session anti-platelet therapy was stopped and asymptomatic obliteration of the ICA occurred. Adequate intracranial perfusion was maintained through the anterior and posterior communicating arteries and the patient was discharged asymptomatic.
Although extremely rare, true carotid aneurysms with sphenoid extension may cause epistaxis, reason why this entity should be included in the differential diagnosis of one of the most common emergencies encountered by otolaryngologists.
Differential Diagnosis List
Cavernous internal carotid artery aneurysm
Final Diagnosis
Cavernous internal carotid artery aneurysm
References
[1] Honeybul S, Barker S, Poitelea C, et al. (2006) Multiple intracranial aneurysms presenting with epistaxis. J Clin Neurosci 13:394-397 (PMID: 16540324)
[2] Chen D, Concus AP, Halbach VV, Cheung SW (1998) Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: diagnosis and endovascular therapy. Laryngoscope 108:326-331 (PMID: 9504602)
[3] Chaboki H, Patel AB, Freifeld S, et al. (2004) Cavernous carotid aneurysm presenting with epistaxis. Head Neck 26:741-746 (PMID: 15287042)
[4] Lehman P, Saliou G, Page C, et al. (2009) 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 266:767-772 (PMID: 18574589)
[5] Renn WH, Rhoton AL. (1975) Microsurgical anatomy of the sellar region. J Neurosurg 43:288-298 (PMID: 1151464)
Case information
| URL: | https://eurorad.org/case/8750 |
| DOI: | 10.1594/EURORAD/CASE.8750 |
| ISSN: | 1563-4086 |
