Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience

Abstract

Background and objective: To describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach.

Methods: We analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative "sandwich technique" combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed.

Results: No patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus.

Conclusions: Although the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.

Keywords: Acute vascular injury; Cavernous carotid artery; Endoscopic endonasal; Flow diverter stent; Hadad flap; Skull base surgery.

Fig. 1

Endoscopic endonasal “sandwich technique” with Hadad flap harvesting (case #3). a Left sphenoidotomy. b Harvesting of left nasoseptal flap (Hadad flap). c Nasoseptal flap placed to cover the left sphenoidotomy. d Endonasal endoscopic image at 22 months, showing complete healing of the nasoseptal flap in the sphenoid as well as the nasal septum donor site

Fig. 2

Case #3 is a 48-year-old woman admitted to our institution for sudden epistaxis. She was affected by recurrent chronic rhinosinusitis with nasal polyps treated at another center with radical spheno-ethmoidectomy with maxillary and frontal sinusotomies about 1 month before. A diagnostic CTA and DSA documented a PSA of the anterior profile of the left carotid siphon. An FDS (FRED, 4 × 12/18 mm) was placed. a Pre-procedural DSA showing PSA of the anterior genu right cavernous ICA segment. b Intra-procedural DSA showing FDS correct placement. c DSA at 3 months, demonstrating the regular cavernous ICA profile, without evidence of PSA recurrence

Fig. 3

Case #4 is a 48-year-old man with pituitary GH-secreting macroadenoma. The lesion was approached with an endoscopic trans-sphenoidal paraseptal binostril approach. An intraoperative cavernous ICA medial wall damage occurred during the sphenoidotomy. Immediate bleeding control was achieved by direct packing with hemostatic agent (oxidized regenerated cellulose, Surgicel® Original, Ethicon, Inc., NJ, USA) of the sphenoid sinus and nasal cavity. The patient was immediately moved to the angiographic room to manage the injured vessel. a Pre-procedural DSA showing a PSA of the anterior genu right cavernous ICA segment. b Intra-procedural DSA showing FDS correct placement. c and d DSA at 12 months demonstrating the appropriate occlusion of the PSA (c) and correct FDS placement (d)

Fig. 4

Case #5 was a 54-year-old male affected by poorly differentiated sphenoid sinus squamous cell carcinoma (pT4bN0M0), extended bilaterally to cavernous sinuses and with a 360° encasement of right ICA, previously submitted to chemotherapy (2 cycles of cisplatin and paclitaxel) and intensity-modulated proton beam therapy (70 Gy). The patient experienced massive epistaxis, investigated with diagnostic imaging, including CTA and DSA, which showed cavernous ICA PSA. The bleeding was controlled by FDS placement. a and b Pre-procedural CTA (a) and DSA (b) showing anterior genu right ICA cavernous segment PSA. c Intra-procedural DSA showing FDS correct placement. d CTA at 1 month demonstrating PSA resolution