- Department of Neurosurgery, University of Maryland, Medical Center, Baltimore, Maryland, USA
- Department of Neuro-Interventional Radiology, University of Maryland, Medical Center, Baltimore, Maryland, USA
- Department of Otolaryngology, University of Maryland, Medical Center, Baltimore, Maryland, USA
- Department of Neurological Surgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
Department of Neurological Surgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
DOI:10.4103/2152-7806.130561Copyright: © 2014 Patel AP. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Patel AP, Gandhi D, Taylor RJ, Woodworth G. Use of Dyna CT in evaluation and treatment of pseudoaneurysm secondary to craniofacial tumor resection: Case report and diagnostic implications. Surg Neurol Int 11-Apr-2014;5:48
How to cite this URL: Patel AP, Gandhi D, Taylor RJ, Woodworth G. Use of Dyna CT in evaluation and treatment of pseudoaneurysm secondary to craniofacial tumor resection: Case report and diagnostic implications. Surg Neurol Int 11-Apr-2014;5:48. Available from: http://sni.wpengine.com/surgicalint_articles/use-of-dyna-ct-in-evaluation-and-treatment-of-pseudoaneurysm-secondary-to-craniofacial-tumor-resection-case-report-and-diagnostic-implications/
Background:Digital subtraction angiography (DSA) is considered the gold standard for the evaluation of head and neck vascular abnormalities. It serves as a useful diagnostic and, in many cases, therapeutic tool for treatment of acute head and neck bleeding.
Case Description:We report the case of a patient who presented with life threatening, uncontrollable epistaxis several weeks after resection of a large recurrent chondrosarcoma of the nasal cavity and anterior skull base. A DSA study, with an adjunctive C-arm computed tomography (CT) (Dyna CT), was ultimately helpful in revealing and precisely localizing a large anterior ethmoidal artery pseudoaneurysm adjacent to the tumor resection cavity.
Conclusion:This additional information helped define the arterial anatomy in postoperative region, allowed precise localization and direct ligation of the pseudoaneurysm to resolve the bleeding with a favorable patient outcome.
Keywords: Craniofacial chondrosarcoma, dyna CT, ethmoidal pseudoaneurysm
Digital subtraction angiography (DSA) is considered the gold standard for the evaluation of craniocervical vascular abnormalities.[
We report a case of a patient who presented with life threatening, uncontrollable epistaxis weeks after resection of a recurrent craniofacial chondrosarcoma. A DSA study, with adjunctive Dyna CT, was ultimately helpful in revealing an anterior ethmoidal artery pseudoaneurysm adjacent to the tumor cavity. The adjunct of Dyna CT was crucial in localizing, diagnosing and treating a rare and fatal vascular lesion.
A 24-year-old, otherwise healthy, male initially presented with a large, recurrent chondrosarcoma of the anterior skull base. This was the third recurrence in the last 5 years, with the tumor showing signs of aggressive growth. Radiotherapy had been previously attempted with no success. Gross total resection transcranially of the tumor with skull base reconstruction was successfully achieved, and patient was discharged home with no issues. The patient then developed severe, life-threatening epistaxis, 3 weeks postresection, for which he was rehospitalized. CT and magnetic resonance imaging (MRI) could not identify the source of bleeding. Brisk arterial bleeding despite intraoperative nasal packing prompted endoscopic and surgical exploration. Initially, the source was thought to be along the right skull base. A right Lynch incision was made during surgical exploration to ligate the right anterior ethmoidal artery. This incision started at the medial aspect of the eyebrow and continued inferiorly halfway down the nasal sidewall, and provided access to the anterior and posterior ethmoidal arteries as well as to the orbital apex, optic nerve, and entire orbital roof. However, this did little to control the brisk bleeding from the nasal cavity and facial incision, and did not allow for localization of the bleeding.
When the source could not be identified on surgical exploration, the wound was packed again and the patient emergently transferred to the DSA suite. The right carotid injections revealed postoperative alterations and failed to identify a definitive source of bleed. Subsequent left internal carotid injection revealed a large (12×10 mm) pseudoaneurysm arising from the anterior ethmoidal branch of the ophthalmic artery [Figures
The treatment options consisted of endovascular embolization versus surgical ligation. Although technically feasible, endovascular embolization via the ophthalmic artery was felt to be associated with an unacceptable risk of visual loss. However, with the precise localization of pseudoaneurysm on Dyna CT, the surgical approach was deemed more desirable and lower risk. Prompt surgical ligation with excellent hemostasis was achieved. The patient was transferred to the intensive care unit and monitored closely. He was extubated the following day with no recurrent epistaxis. Patient was eventually discharged to home at his baseline 5 days after being readmitted.
This report presents a rare case in which an ethmoidal artery pseudoaneurysm was the source of severe, pulsatile epistaxis weeks after surgical resection of a nasal cavity, anterior skull-base chondrosarcoma. More importantly, it highlights the value of DSA and specifically of C-arm (Dyna) CT, a relatively new addition to the armamentarium of neuro-interventionists.
Surgical exploration and ligation of an arterial bleeding source can be challenging, particularly in the context of markedly abnormal anatomy. This holds even more true with previously resected lesions with altered anatomy.[
While a DSA by itself adequately delineated the abnormal bleeding vessel and its origination, the C-arm CT provided further anatomical knowledge of the location of the lesion in relation to the orbital and sinus walls and ultimately provided greater understanding of the relationship of the lesion to the surgical cavity. This information obtained by Dyna CT was considered invaluable for operative planning in this difficult case.
Pseudoaneurysms comprise less than one percent of all intracranial aneurysms. While already so rare, the majority of pseudoaneurysms in the literature have been associated with the internal carotid artery (ICA) and anterior cerebral artery (ACA).[
Iatrogenic pseudoaneurysms are typically considered high risk for rupture, with consequent subarachnoid hemorrhage, carotid-cavernous fistula (CCF) or epistaxis.[
Treatment of these lesions is typically challenging. Direct surgical repair of such lesions involve clipping, wrapping, trapping, and ligation.[
Traditionally, DSA has been the standard method in diagnosing and characterizing cerebrovascular lesions.[
Dyna CT, which is generally used with DSA, is another valuable imaging option and provides complementary information. Dyna CT is able to provide additional soft tissue and bony details, enhance the 3D interpretation of DSA without requiring various oblique projections, repeated selective angiography, higher doses of contrast and radiation, and longer examination times.[
Furthermore, Dyna CT precisely delineates the topographic relationship between the vascular lesion and surrounding osseous structures, thus making surgical planning more accurate.[
The use of Dyna CT certainly contributes in minimizing the disadvantages of conventional DSA encountered by neuro-interventionists.[
In this report, we presented a rare case in which a pseudoaneurysm was found to be the source of persistent epistaxis weeks after a craniofacial-skull base tumor resection. CT/MRI and initial surgical exploration were not able to reveal the source of and control the bleeding. Further imaging with DSA and Dyna CT were used to diagnose and locate a large pseudoaneurysm. This additional information, with the help of increased resolution and accurate localization via the Dyna CT, enabled the team to successfully complete a direct repair with favorable clinical outcome.
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