Delayed massive epistaxis from traumatic intracranial aneurysm after blunt facial injury

Abstract

Cases: Traumatic intracranial aneurysm following blunt head injury is uncommon but can be induced by extension of skull base fracture and causes unexpected hemorrhagic complications. We present two cases of traumatic intracranial aneurysm in the paraclinoid area that was revealed by delayed massive epistaxis. Lack of initial neurological deficits omitted screening for cerebrovascular injury.

Outcome: Internal trapping was carried out using endovascular techniques in both cases, with extracranial-intracranial bypass in one case. No recurrent bleeding occurred in either case.

Conclusion: To prevent unexpected delayed life-threatening hemorrhagic accidents, careful assessment of skull-base fracture is prerequisite, even in cases of mild facial injury.

Keywords: Blunt facial injury; endovascular trapping; extracranial–intracranial bypass; massive epistaxis; traumatic intracranial aneurysm.

Figure 1

Case 1 of delayed massive epistaxis from traumatic intracranial aneurysm after blunt facial injury. A, B, Three‐dimensional image and axial‐slice computed tomography illustrating zygomatic bone fracture (A, arrowheads) and maxillary bone fracture (B, arrowheads). C, D, Maximum intensity projection image of thin‐slice computed tomography showing extension of the fracture line to the sella turcica and ethmoid bone (arrowheads). E, Angiography revealing aneurysmal formation on the internal carotid artery in the paraclinoid area (arrowhead). F, Three‐dimensional image of the aneurysm acquired by 3D‐rotational angiography (arrowheads). G, Internal trapping using detachable coils (arrowheads). H, Magnetic resonance angiography after endovascular treatment. Collateral flow is seen through the anterior communicating artery and posterior communicating artery. I, Positron emission tomography at 12 months postoperatively. No decline in cerebral blood flow is apparent.

Figure 2

Case 2 of delayed massive epistaxis from traumatic intracranial aneurysm after blunt facial injury. A, B, Three‐dimensional image and axial‐slice computed tomography showing maxillary bone fracture (arrowheads). C, Axial‐slice CT angiography showing the fracture line at the lateral wall of the sphenoid sinus. D, Pooling of contrast medium in the sphenoid sinus, suggesting traumatic pseudoaneurysm. E, Angiography revealing aneurysm formation on the internal carotid artery in the paraclinoid area (arrowhead). F, Three‐dimensional image of aneurysm acquired by 3D‐rotational angiography. G, Extracranial–intracranial bypass using radial artery graft (yellow arrowheads) and internal trapping using detachable coils (red arrowheads). H, Post‐procedural magnetic resonance angiography showing collateral flow through radial artery graft (arrowheads). I, Single photon emission computed tomography at 1 month after procedures, showing no decline in cerebral blood flow.