Traumatic Internal Maxillary Artery Pseudoaneurysm with a Malunited Mandibular Fracture

Abstract

Post-traumatic external carotid artery pseudoaneurysms are very uncommonly encountered in clinical practice. We present the case of a young man who developed pseudoaneurysm 5 weeks after a maxillofacial injury treated elsewhere. Case PresentationA 23-year-old male presented with a history of swelling over the left side of face since 1 week. He had a history of road traffic accident 5 weeks ago. He was treated elsewhere after the injury by tracheostomy, open reduction and internal fixation of his mandibular symphysis fracture with closed approach for his condylar head fractures. On examination, the patient had left sided facial palsy, tender diffuse swelling over left side of face and neck, trismus and dental malocclusion. A computed tomography (CT) scan with angiography was performed which revealed a pseudoaneurysm of the terminal branch of external carotid artery about 6.6 9 4.9 9 8.9 cm in diameter AP/RL/CC (Fig. 1). Bilateral sagitally fractured condylar heads and left coronoid process fractures were noted with lateral flaring of the left mandible. Symphysis was fixed using plates and screws (Fig. 2). The radiologist interpreted on CT scan that the origin of the pseudoaneurysm was most likely to be the superficial temporal artery.The treatment plan was surgical repair of the superficial temporal artery pseudoaneurysm and correction of the malocclusion by mandibular repositioning. A preauricular incision was made, the pseudoaneurysm identified and the superficial temporal artery was doubly ligated. On opening the pseudoaneurysm wall, to our surprise, there was a torrential bleed from within, thus raising the possibility of another source of the pseudoaneurysm origin. With pressure applied locally, an extension of the incision in the neck to a parotidectomy type was made. The external carotid artery (ECA) was identified and a vascular control sought. ECA control was then tightened to minimize the bleeding and 5-0 polypropylene (Prolene, Ethicon) was used to suture repair the rent in distal part of internal maxillary artery from within the pseudoaneurysm cavity. Hemostasis was confirmed after releasing the ECA. The symphyseal fracture was re-osteotomized using an existing chin scar, and the entire left mandible mobilized medially at the ramal angle to correct the flaring, two 2.5 mm miniplates were secured with eight screws at the symphysis. A satisfactory neoocclusion was achieved. A suction drain was applied and closure was done in layers. The post-operative course was uneventful (Fig. 3). DiscussionIn the head and neck, blunt, penetrating or surgical trauma can infrequently lead to damage of vessels resulting in pseudoaneurysms. The diagnosis of these vascular complications is made easy with the availability of CT angiography [1,2]. A CT scan also is advantageous in assessing the artery of origin and relation of the pseudoaneurysm with the bony fractures and planning the treatment strategy. In our patient depending on the CT angiography, we however misinterpreted the pseudoaneurysm in the pre-auricul...

Pseudoaneurysm of the internal maxillary artery secondary to subcondylar fracture: case report and literature review

“…In six cases, the diagnosis was performed only by CT angiography, between these in one case [ 14 ] the surgeons misinterpreted the PA to be arising from the superficial temporal artery while the feeding vessel was the maxillary artery.…”