内視鏡下鼻内副鼻腔手術中の大量出血にて発覚した外傷性仮性内頸動脈瘤例

抄録

We report the case of a patient with traumatic pseudoaneurysm, who developed massive bleeding during endoscopic sinsu surgery.

A 23-year-old drunk man sustained severe injuries when he fell from the second floor of his home and was transported to the hospital emergency department. He was diagnosed as having traumatic subarachnoid hemorrhage, brain contusion, skull base fracture, pneumoencephalopathy, maxillary fracture, right distal radius fracture, and admitted to the hospital. He was transferred to our oral surgery department for maxillary fixation to treat the maxillary fractures. Cerebrospinal fluid rhinorrhea was suspected due to a skull base fracture, and the patient was referred to the otorhinolaryngology department. Since there was no obvious cerebrospinal fluid leakage, the patient was followed up. However, as the rhinorrhea persisted, endoscopic sinus surgery was performed under general anesthesia to confirm and treat cerebrospinal fluid leakage. The sphenoid sinuses of both sides were filled with clot-like masses with strong pulsations. Hematomas were suspected, but when a piece of tissue was removed from the left sphenoid sinus mass, arterial bleeding occurred. Hemostasis was accomplished by immediate compression with gauze.

Emergency cerebral angiography revealed a pseudoaneurysm in the right internal carotid artery, and pseudoaneurysm trapping (internal carotid artery blockage) with STA-MCA bypass and high flow bypass (ECA-RAG-MCA) was performed. After the operation, there was no apparent paralysis, and MRI revealed no apparent infarct. Four years after the operation, there is no evidence of aneurysm recurrence. This case suggests that in cases that develop refractory epistaxis after head injury, traumatic internal carotid artery pseudoaneurysm must be considered in the differential diagnosis, and cerebral angiography must be performed immediately.