Embolization for treating posttraumatic pseudoaneurysm of the sphenopalatine artery

Abstract

Posttraumatic pseudoaneurysms of the sphenopalatine artery are rare. Only a few cases have been reported. We report two cases of hemorrhage due to pseudoaneurysm of the sphenopalatine artery. The hemorrhage was uncontrollable. It required embolization. Two patients visited our hospital for treatment of zygomaticomaxillary complex fracture. At the emergency room, patients presented with massive nasal bleeding which ceased shortly. After reduction of the fracture, patients presented persistent nasopharyngeal bleeding. Under suspicion of intracranial vessel injury, we performed angiography. Angiograms revealed pseudoaneurysms of the sphenopalatine artery. Endovascular embolization was performed, leading to successful hemostasis in both patients. Due to close proximity to pterygoid plates, zygomaticomaxillary complex fracture involving pterygoid plates may cause injury of the sphenopalatine artery. The only presentation of sphenopalatine artery injury is nasopharyngeal bleeding which is common. Based on our clinical experience, although pseudoaneurysm of maxillary artery branch after maxillofacial trauma has a low incidence, suspicion of injury involving deeply located arteries and early imaging via angiogram are recommended to manage recurrent bleeding after facial trauma or surgery.

Pseudoaneurisma de artéria esfenopalatina após agressão por arma de fogo em face

“…Em trauma penetrante, o mecanismo de trauma é de alta velocidade, em que fragmentos de osso ou de projéteis podem levar a laceração arterial (Alonso et al, 2016). PAS são extremamente raros por causa da sua localização profunda e proteção pela estrutura óssea (Chun et al, 2019), porém, se não tratado, ele tende ser potencialmente fatal, devido a: hemorragias intracraniana / extracranianas, oclusão vascular, tromboembolismos e compressão dos nervos adjacentes (Alonso et al, 2016), dessa forma, merece tratamento de urgência (Gon et al, 2015). O risco de ruptura do pseudoaneurisma é muito mais elevado do que um aneurisma verdadeiro, uma vez que há menos suporte da parede do vaso (Alonso et al, 2016).…”

“…Se persistir hemorragia após trauma facial a intervenção precoce com métodos de imagem como a tomografia computadorizada e angiografia é recomendada, para o estudo de uma possível embolização vascular (Lee et al, 2009;Bonnecaze et al 2018;Chun et al, 2019). Nesse relato, a angiografia não foi realizada imediatamente, porque os tamponamentos nasais foram eficazes para cessar o sangramento no momento inicial.…”

“…Consequentemente, há presença de inflamação e de tecido fibroso sobreposto ao endotélio. Com a evolução, a pressão arterial aumenta o tamanho e a forma do pseudoaneurisma, tornando a parede fina e frágil (Baek and Cho, 1984;Krishnan et al, 2004;Campbell et al, 2012;Gökdoǧan et al, 2014;Alonso et al, 2016;Chun et al, 2019).…”

Ruptured pseudoaneurysm of the internal maxillary artery in zygomaticomaxillary fracture: a case report

“…Pseudoaneurysm is a rare life-threatening complication; it comprises an arterial wall breach that allows the extravasation of blood into the neighboring tissues [ 1 , 2 ]. A hematoma formed by damage to the arterial wall is replaced by fibrous walls, which expand due to the continuous pulsating pressure and form a pseudoaneurysm [ 1 , 3 ]. Because the wall of a pseudoaneurysm is weaker than that of a true aneurysm, pseudoaneurysms are especially dangerous and have a higher possibility of rupture [ 4 ].…”

“…Only a few cases of preoperatively discovered post-traumatic pseudoaneurysms that affected the internal maxillary artery after a facial bone fracture have been reported. In these cases, the bleeding occurred postoperatively [ 3 , 4 , 6 ]. Herein, we report a case of intractable epistaxis that occurred just before open reduction and internal fixation (ORIF) in a patient with a zygomaticomaxillary complex (ZMC) fracture.…”