Ruptured aberrant internal carotid artery pseudoaneurysm presenting with spontaneous massive ear bleeding following a single sneeze: a case report

Transcription

1 Case eport JNET 7: , 2013 uptured aberrant internal carotid artery pseudoaneurysm presenting with spontaneous massive ear bleeding following a single sneeze: a case report Seiichiro HIONO 1) Eiichi KOYSHI 1) Koichi EIH 2) Michihiro HYSK 2) Homare SUZUKI 3) Yoshitaka OKMOTO 3) Naokatsu SEKI 1) bstract Objective ( ) Case presentation Conclusion Key Words Introduction ( ) 7) ( - ) Case report JNET Vol.7 No.5 November 2013

2 Hirono S, et al Fig. 1 CT scan on arrival. The aberrant internal carotid artery (IC, arrow) running through the enlarged inferior tympanic canaliculus (ITyC). The aberrant IC (arrow) runs from the posterior in the hypotympanum to the mesotympanum, without a bony plate of the carotid canal. The protruded pseudoaneurysm (arrowhead) is also of note. institute, a physical examination showed hypovolemic To obtain complete hemostasis, a decision was made to shock due to massive bleeding from the right ear. fter interrupt the flow to the i-pseudoaneurysm with coil the external ear canal was packed and sufficient red cell embolization. 7Fr sheath (Terumo-Clinical Supply, concentrates were transfused to stabilize circulation, Tokyo, Japan) was introduced into the right common computed tomography (CT) of the ear (Fig. 1) revealed femoral artery. 7Fr guiding catheter with a balloon that the right IC was markedly situated posterolaterally (Patlive; Terumo-Clinical Supply) was advanced into the with the absence of a bony plate between the middle ear proximal right cervical IC in case proximal flow control cavity and the carotid canal; furthermore, the inferior was needed. microballoon catheter with a 4.5 mm tympanic canaliculus (ITyC) was larger than usual. diameter balloon (ttendant; Terumo-Clinical Supply) Carotid angiography (Fig. 2) showed a laterally was positioned in the aberrant IC proximal to the protruding mm aneurysm at the genu of the pseudoaneurysm, and temporary occlusion was vertical and horizontal segment of the IC, and a performed. Since the patient showed no obvious narrowing of the IC where it entered the ITyC. ased neurological deficits during temporary occlusion, the on these findings together with the patient's one-month trapping procedure was continued. However, a small history of right otorrhea, a diagnosis of spontaneous amount of contrast extravasation from the aneurysm was ruptured i-pseudoaneurysm with aberrant IC was observed when a microcatheter (Excelsior 1018; oston given. Further angiography of the left carotid artery and Scientific, Natick, M, US) was advanced distal to the the dominant left vertebral artery demonstrated good aneurysm. The patient demonstrated slight left filling of the right cerebral hemisphere through the Circle hemiparesis immediately after the extravasation, which of Willis collaterals in addition to flow from the right was probably caused by embolic infarction. middle meningeal artery (MM) to the intracranial IC. Temporary inflation of the 7Fr balloon catheter in the JNET Vol.7 No.5 November

3 Hirono S, et al Fig. 2 () () ( ) 12 - ( ) ( ) (Fig. 3) (Fig. 4) 2 Discussion ) - ( - ) - - 9) JNET Vol.7 No.5 November 2013

4 Hirono S, et al Fig. 3 Post-trapping right internal carotid angiogram, frontal view () and lateral view (). The right IC was completely embolized, and there was good collateral flow from the middle meningeal artery (arrowhead) to the territory perfused by the right IC. first to ensure the accurate diagnosis of aberrant IC7,12). The posterolateralization of the IC in the middle ear cavity and enlarged ITyC are the key findings of an aberrant IC. From an angiographic point of view, it is often difficult to distinguish a lateralized IC (a normal anatomic variant) from an aberrant IC, since some angiographic features are shared2). Therefore, a temporal bone CT scan must be performed in combination with cerebral angiography. riefly, lateralized IC is not normally associated with enlarged ITyC, because it is not the result of partial agenesis of the IC. genu of the lateralized IC protrudes into the anterior mesotym panum, whereas the aberrant IC runs from the posterior of the hypotympanum across the middle ear Fig. 4 Post-treatment MI scan revealing the thrombotic infarction in the right frontal and parietal lobe. cavity to the anterior mesotympanum along the posterior cochlear promontory. Following a CT scan, carotid artery angiography is immediately required for confirmation of the diagnosis and to determine the origin of the bleeding, and again immediate and accurate diagnosis of ruptured following endovascular treatment. efore the i-pseudoaneurysm is essential even though it is more endovascular treatment era, direct surgery or ligation of difficult. temporal bone CT scan should be performed the IC in the neck was the only option to control JNET Vol.7 No.5 November

5 Hirono S, et al ) 1 5 6) ) ) ) - - Conclusion - - eferences JNET Vol.7 No.5 November 2013