Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 389-394

Posttraumatic cavernous internal carotid artery pseudoaneurysm causing massive epistaxis: Our experiences at a tertiary care teaching hospital of eastern India


1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Department of Neurosciences, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
3 Department of Neurosurgery, SUM Ultimate Medicare, Bhubaneswar, Odisha, India

Date of Submission18-May-2020
Date of Decision25-May-2020
Date of Acceptance01-Jun-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_62_20

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  Abstract 


Background: Pseudoaneurysm of the cavernous internal carotid artery (ICA) is an uncommon clinical incidence. This may cause massive epistaxis and pose a life-threatening situation for patient. Aim: The aim of this study to acquaint the clinicians with this rare cause of the massive epistaxis due to posttraumatic pseudoaneurysm of the cavernous ICA. This study evaluates the details of patient's profile including presenting symptoms, investigation, treatment, and outcomes. Materials and Methods: Data of seven patients with cavernous ICA pseudoaneurysm presenting with epistaxis from March 2018 to April 2020 were retrospectively reviewed. Results: The age range of the patients was from 22 to 64 years. Duration of head trauma to the epistaxis ranged from 1 month to 4 months. All had history of head trauma. All were managed by endovascular coil embolization. Conclusion: Cavernous ICA pseudoaneurysm can cause life-threatening epistaxis. Patients present with severe epistaxis and history of head trauma should be thought for traumatic pseudoaneurysm of cavernous ICA. Endovascular coil embolization of the pseudoaneurysm is an important option for effective treatment.

Keywords: Epistaxis, internal carotid artery, pseudoaneurysm, sphenoid sinus


How to cite this article:
Swain SK, Behera IC, Jena S. Posttraumatic cavernous internal carotid artery pseudoaneurysm causing massive epistaxis: Our experiences at a tertiary care teaching hospital of eastern India. Indian J Vasc Endovasc Surg 2020;7:389-94

How to cite this URL:
Swain SK, Behera IC, Jena S. Posttraumatic cavernous internal carotid artery pseudoaneurysm causing massive epistaxis: Our experiences at a tertiary care teaching hospital of eastern India. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Jan 28];7:389-94. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/389/304641




  Introduction Top


Epistaxis is one of the most common emergencies in otorhinolaryngological practice. Massive epistaxis often leads to distress in patients and treating clinicians. In general population, more than half of the people have experience of epistaxis with varying severities.[1] Medical intervention is required in around 6% of these patients because of the rarity of the massive epistaxis.[1] Injury to the nasal wall mucosal membrane, dryness of the nasal cavity mucosa, hypertension, anticoagulation therapy, and bleeding disorders are common causes of the epistaxis.[2] Vascular abnormalities and trauma contribute to <5% of all the cases of nasal bleeding.[3] Pseudoaneurysm affecting the cavernous internal carotid artery (ICA) is uncommon and it accounts for only 3%–5% of all the intracranial aneurysm.[4] Although head injury is a known cause for epistaxis, traumatic pseudoaneurysm of ICA is a very rare cause of the epistaxis after head trauma. If posttraumatic cavernous pseudoaneurysm of ICA is unrecognized, it may lead to mortality. Management of this fatal clinical entity is unique and challenging than other causes of the epistaxis. The objective of this study is to report detail patient profile and management of the posttraumatic cavernous ICA pseudoaneurysm causing massive epistaxis at a tertiary care teaching hospital.


  Materials and Methods Top


We retrospectively analyzed the cases of posttraumatic cavernous ICA pseudoaneurysm leading to massive epistaxis treated at our tertiary care teaching hospital during March 2018 to April 2020. This study was approved by the institutional ethics committee, and informed consent was obtained from each patient. The medical records of the patients with posttraumatic pseudoaneurysm of the cavernous ICA treated at our tertiary care teaching hospital were reviewed. The information such as type of head injury, presenting symptoms, treatment, and outcomes were analyzed in this study. Total seven cases were analyzed in this study. Computed tomography (CT) angiography was done in each case for finding the vascular anomalies. Diagnostic carotid angiogram was performed to localize the pseudoaneurysm. All the treatment procedures were performed by the interventional neuroradiologists. After endovascular therapy, all patients were closely monitored for any neurological deficits and hemodynamic parameters for at least 72 h. All the participating patients were clinically evaluated at the follow up visit on 1st, 3rd, and 12th months after endovascular coil embolization. Imaging such as CT scan, magnetic resonance imaging (MRI), and angiography was done one to 12 months after embolization to evaluate the coil position and ICA occlusion.

Case 1

A 22-year-old male attended the Emergency Department with massive epistaxis from the left nostril for 1 day. Immediately, anterior nasal pack was given, so the bleeding from the nose stopped. The blood pressure was low with 90/60 mmHg. He was resuscitated with intravenous fluid. After 48 h of nasal pack, this anterior nasal pack was removed and there was no active nasal bleeding. He had a history of head trauma 4 months back by road traffic accident, which resulted in loss of the vision of the left eye. He had no history of the nasal bleeding at the time of the head trauma. However, there was mild left nasal bleeding after 1 month of the head trauma. Diagnostic nasal endoscopic showed no active bleeding point or mass lesion except blood clots in the left nasal cavity. On the basis of the history and examination, a traumatic pseudoaneurysm of the right ICA was suspected. CT angiography was done, which demonstrated a lobulated pseudoaneurysm of the cavernous part of the left ICA, which protruded into the anterior sphenoid sinus [Figure 1]. Endovascular coil embolization [Figure 2] was done with successful outcome. He was recovered well and discharged without any neurological deficits. He was symptom free at follow-up visit after 1 year.
Figure 1: Computed tomography angiography showing a lobulated pseudoaneurysm of the cavernous part of the left internal carotid artery which protruded into left side of the sphenoid sinus (yellow arrow mark)

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Figure 2: Endovascular coil embolization for pseudoaneurysm of the ruptured cavernous internal carotid artery pseudoaneurysm (yellow arrow mark)

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Case 2

A 28-year-old male attended the emergency department with severe epistaxis. He had a history of mild blunt trauma to the head 1 month back during a road traffic accident. He had no history of epistaxis at the time of head injury. After 1 month of head trauma, he developed severe epistaxis, so attended the emergency department. His blood pressure was normal. He was treated with immediate anterior nasal pack in both nostrils. Once bleeding stopped after nasal packing, the routine blood tests were sent for investigations. The bleeding parameters were within normal limits. After 48 h, the nasal pack was removed. There was no active bleeding after removal of the nasal pack. Then a noncontrast CT scan of the paranasal sinus and brain was done for anticipating any injury. CT scan showed erosion of the sphenoid sinus with protrusion of the soft tissue into the sinus. CT scan with angiographic study was advised, which revealed right ICA pseudoaneurysm projecting into the right sphenoid sinus through a bony defect at the roof of the sphenoid sinus [Figure 3]. Angiogram was done after right transfemoral catheterization, which showed a vascular protrusion or pseudoaneurysm of the cavernous ICA into the right side of the sphenoid sinus. The severity of the epistaxis, imaging, and the history of the head trauma lead to the diagnosis of the cavernous ICA pseudoaneurysm. The patient was referred to the interventional neuroradiologist for endovascular coil embolization. The cavernous ICA pseudoaneurysm was treated with coil embolization. A digital subtraction angiogram (DSA) showed detachable coil embolization with preservation of the carotid flow. The patient was recovered well and discharged without development of any neurological deficits. He was asymptomatic at follow-up visit after 1 year.
Figure 3: Computed tomography scan with angiography showing bony defect in the right side of the sphenoid side through which cavernous internal carotid artery pseudoaneurysm entering into the right side of the sphenoid sinus (yellow arrow mark)

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Case 3

A 32-year-old male attended the outpatient department of otorhinolaryngology with a history of three episodes of nasal bleeding in the last 3 months. He had a history of head injury by fall from the height 3 months back. CT angiography revealed a pseudoaneurysm of cavernous ICA protruding to the left side of the sphenoid sinus. The patient underwent endovascular coiling of the pseudoaneurysm. He developed transient right side weakness and dysphagia, which resolved after few hours of the coil embolization. The patient was discharged after symptom free. At 1-year follow-up visit, the patient is asymptomatic.

Case 4

A 36-year-old male attended the outpatient department of the otorhinolaryngology with a history of two episodes of the epistaxis from his left nostril duration the period of the last 3 months. The last episode of the epistaxis was massive and uncontrolled, which prompted him for medical specialist consultation. He had a history of motor vehicle accident 3 months back prior to the first episode of the epistaxis. At the time of motor vehicle accident, it was associated with transient loss of consciousness, vomiting, and nasal bleeding. He has loss of the vision in the left eye with proptosis [Figure 4]. CT scan revealed fracture of the sphenoid sinus in the left lateral side. At that time, he was managed with anti-epileptics, antibiotics, and close observation for cerebrospinal fluid leak. Then, he was discharged with his Glasgow coma scale 15 and without any perceivable vision in his left eye. At the time of hospitalization, his hemoglobin levels had dropped to 6.2 g/dl. The endonasal and medical causes of the epistaxis were ruled out. In view of the past head trauma with epistaxis and blindness, a CT angiogram of the brain was done which revealed a saccular pseudoaneurysm of the cavernous part of the right ICA. Then, DSA was done to confirm the flow and cross-circulation across the hemispheres and plan for surgery. The DSA showed a left cavernous segment of the ICA pseudoaneurysm with moderate cross-circulation from the right side ICA. There was no evidence of any fistulous connection. The patient was explained for endovascular coil embolization. Then, he underwent endovascular embolization [Figure 4].
Figure 4: Patient presenting with left eye proptosis with loss of vision

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Case 5

A 55-year-old female attended the emergency department with massive epistaxis. Emergency physician immediately packed the nasal cavity, so the bleeding from the nasal cavity stopped. She had a history of two episodes of nasal bleeding in the last 4 months. She had a history of head trauma 4 months back by fall from the height. CT angiography confirmed the pseudoaneurysm of cavernous ICA protruding to the left side of the sphenoid sinus. Then, the patient underwent endovascular coil embolization. The patient becomes symptom free since the last year after coil embolization.

Case 6

A 59-year-old male faced a road traffic accident and was managed conservatively for left temporal extradural hematoma 3 months back. After 3 months of the road traffic accident or head injury, he came to the emergency department with massive nasal bleeding from left nostril. He had also loss of vision in the left eye. The rest of the neurological and physical examinations were within normal limits. CT angiography revealed the pseudoaneurysm of the cavernous ICA at the left side of the sphenoid with defect in the bony wall of the sinus. The patient was sent to interventional neuroradiologist and underwent endovascular coil embolization. Carotid angiography was done and showed complete exclusion of the pseudoaneurysm from the circulation. The patient was asymptomatic at 1-year follow-up visit.

Case 7

A 64-year-old female presented with two episodes of massive epistaxis since 3 months after road traffic accident with trauma to the head. She had no cranial nerve dysfunction. MRI scan showed a small signal void aneurysm in the sphenoid sinus with surroundings hypointense blood clots in both T1- and T2-weighted spin echo images. Further CT angiography confirmed the bony erosion of the right wall of the sphenoid sinus through which the pseudoaneurysm protruding to anteroinferior part of the sphenoid sinus. The pseudoaneurysm was treated with endovascular coil embolization. The patient is symptom free at 1-year follow-up visit.


  Results Top


Out of the seven patients of cavernous ICA pseudoaneurysm, five were male (71.42%) and two were female (28.57%). The age ranges of the participating patients were from 22 years to 64 years. All of them present with massive epistaxis. All had a history of blunt trauma to the head. The duration of the head trauma to epistaxis ranged from 1 month to 4 months. Hence, the time course for clinical presentations such as massive life-threatening epistaxis has variable durations. Out of the seven cases, 5 (71.42%) presented with recurrent episodes (more than one episode) of the epistaxis. Out of seven cases, 3 (42.85%) patients had decreased vision. One had associated proptosis. All had a history of the blunt trauma to the head. All the seven patients revealed pseudoaneurysm of the cavernous ICA with the help of carotid angiography. In these cases, the diagnosis was suspected by history and findings in CT and/or MRI. Carotid angiography was done to give definitive diagnosis. All the patients in this study were successfully treated by coil embolization by interventional neuroradiologists. All the case details are summarized in [Table 1].
Table 1: Clinical profile of the patients with cavernous internal carotid artery pseudoaneurysm

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  Discussion Top


Posttraumatic pseudoaneurysm of the cavernous ICA is an uncommon incidence and seldom considered as etiology for the epistaxis in initial patient evaluation. However, this is a life-threatening situation for patients and poses a challenge to the clinicians. Although posttraumatic pseudoaneurysm of the cavernous ICA is a rare clinical incidence, it may be a potential cause for the massive epistaxis.[5] The first documented case of the posttraumatic pseudoaneurysm of cavernous ICA in 1928 where a young man presented with massive epistaxis after 6 months of trauma to the head.[6] However, the patient had no pathological or radiological confirmation and treated with ligation of the carotid artery. However, despite its rare occurrence, this lesion carries a higher rate of mortality. Majority of the cases of cavernous ICA pseudoaneurysm are associated with trauma and have 30%–50% chance of mortality rate.[7] Other than head trauma, causes of the pseudoaneurysm of ICA are associated with mycotic, congenital, and inflammatory etiologies.[8] Pseudoaneurysm occurs because of the formation of the hematoma at ICA from the peripheral fibrous wall. Continuous pulsatile forces from ICA weaken and enlarge the hematoma and may results in break the fibrous wall and may cause rupture with massive epistaxis. Traumatic aneurysm of the ICA is often seen in its cavernous and petrous parts. Majority of the traumatic pseudoaneurysm of ICA leading to the severe epistaxis are found at the cavernous segment and rupture into the sphenoid sinus. The anatomical assessment of the sphenoids in cadavers show bulging of the ICA into the lateral wall of the sphenoid sinus in approximately 71% of cases.[9] The bony covering of the ICA is <1 mm of thickness in approximately 66% of the cases.[9] In 50% of the population, the bony wall of the sphenoid sinus is <0.5 mm thick.[10] There is dehiscence of bony partition between the bony wall of the sphenoid sinus and ICA in 4% of the cases.[11] This anatomical relationship allows for expansion of the cavernous ICA pseudoaneurysm into the sphenoid sinus in anteromedial direction.

There are several mechanisms for explaining the formation of the pseudoaneurysm of ICA after blunt or penetrating injury. Tear at the intimal layer of the ICA can be augmented by dissection of blood, which finally leads to reduced blood flow and formation of thrombus in the lumen.[12] The process of the arterial weakening is not sudden and the latent period between the trauma and onset of the epistaxis is often variable. This process can take days to years with average duration approximately 3 weeks (88% of cases).[12] The pseudoaneurysm of the cavernous ICA is proximity to the certain vital structures such as cranial nerves II, III, IV, V, and VIth and also ophthalmic artery. Clinically patients of the cavernous ICA pseudoaneurysm present classically with massive epistaxis, unilateral blindness, and orbital fractures.[13] Early attention to this triad can give diagnosis of cavernous ICA pseudoaneurysm as the cause of the massive epistaxis so that early intervention can be started. Posttraumatic pseudoaneurysm of the ICA causes epistaxis often within 3 weeks after initial injury (88%); however, massive epistaxis may be delayed by months or years.[14] Early episode of epistaxis is typically is not as severe, but in recurrent episodes, the nasal bleeding is more severe. The initial epistaxis may not be impressive and so the diagnosis and treatment may be delayed. In all of the cases except one in our study, the diagnoses were made only after massive epistaxis. The explanation for delayed massive epistaxis is by the time required for traumatic event to weaken the ICA wall and the pulsatile pressure to erode via the intact bony wall of the sphenoid sinus.[15] Rarely, the pseudoaneurysm of the cervical ICA rupture into the posterior part of the nasopharynx and eustachian tube.

The diagnosis of pseudoaneurysm of ICA causing epistaxis is usually elusive and delayed. Carotid angiography is considered as the gold standard for diagnosis of the suspected vascular injury.[16] In our study, the diagnosis of the cavernous ICA pseudoaneurysm was confirmed after performing the carotid angiography. However, CT scan and MRI are often done after the head trauma. Certain findings in CT and MRI prompt to perform the carotid angiography for further assessment. In MRI, T1-weighted hyperintense and T2-weighted hypointense signals at the sphenoid sinus suggest blood clots and prompt to do angiography. Moreover, the MRI may reveal the presence of the pseudoaneurysm.[4] CT scan help assess the bony fractures of the sphenoid sinus, sella turcica, and orbital apex area and the presence of the fractures in these sites increase the suspicion of ICA pseudoaneurysm. However, pseudoaneurysm may be formed in the absence of the bony fractures. Hence, negative CT scan findings do not exclude the diagnosis of the ICA pseudoaneurysm. Carotid angiography classically exhibits an out pouching from the ICA, which is the wall of the ICA pseudoaneurysm. The lumen of the pseudoaneurysm is often radiopaque and fills with the contrast. However, early angiogram may not show a developing pseudoaneurysm lumen. In all of our cases, immediate angiography was within normal limits, but repeat angiography after 2 weeks demonstrates the pseudoaneurysm.

The treatment options of the cavernous ICA pseudoaneurysm include detachable balloon and/or coil embolization. These techniques are better than surgical clipping or ligation and these may be opted in areas that are relatively inaccessible. Endovascular approach is useful for treating posttraumatic cavernous ICA pseudoaneurysm.[17] Endovascular embolization helps occlude the proximal and distal to the pseudoaneurysm, leading to the complete exclusion of the lesion from arterial circulation of the ICA of the cervical part, which often causes recurrent bleeding from the collateral flow. Postembolization arteriogram confirms the complete occlusion of the pseudoaneurysm. Pseudoaneurysm of ICA ruptures easily than true aneurysm. Stent-assisted coiling is a preferred option with patent vessel preservation or carotid artery sacrifice using coils or balloons.[18] In this study, endovascular coil embolization of the cavernous ICA pseudoaneurysm was done with successful outcome. No patients of this study presentenced with recurrence of epistaxis in their follow visit. All of them were symptom free after 1-year follow-up visit.


  Conclusion Top


Traumatic pseudoaneurysm of the cavernous part of the ICA is a challenging clinical entity both in diagnosis and treatment. Posttraumatic pseudoaneurysm of ICA may be missed on presentation as there may not have any nasal bleeding or only minor bleeding at the time of head trauma. Posttraumatic intracavernous ICA pseudoaneurysm is a rare fatal complication of the head injury. This clinical manifestation should be suspected in patients with a history of head injury, massive recurrent epistaxis, and delayed onset of blindness. Massive epistaxis after head trauma should alert the clinician for possible cavernous ICA pseudoaneurysm. CT angiography helps diagnose the cavernous ICA pseudoaneurysm. Endovascular stent-assisted coil embolization is an effective mode of treatment for the pseudoaneurysm. Timely diagnosis and early treatment of the cavernous ICA pseudoaneurysm provides a favorable outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Elahi MM, Parnes LS, Fox AJ, Pelz DM, Lee DH. Therapeutic embolization in the treatment of intractable epistaxis. Arch Otolaryngol Head Neck Surg 1995;121:65-9.  Back to cited text no. 1
    
2.
Chen D, Concus AP, Halbach VV, Cheung SW. Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: Diagnosis and endovascular therapy. Laryngoscope 1998;108:326-31.  Back to cited text no. 2
    
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Juselius H. Epistaxis. A clinical study of 1,724 patients. J Laryngol Otol 1974;88:317-27.  Back to cited text no. 3
    
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Goleas J, Mikhael MA, Paige ML, Wolff AP. Intracavernous carotid artery aneurysm presenting as recurrent epistaxis. Ann Otosl Rhinol Laryngol 1991;100:577-9.  Back to cited text no. 4
    
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Menon G, Hegde A, Nair R. Post-traumatic cavernous carotid pseudoaneurysm with delayed epistaxis. Cureus 2018;10:e3002.  Back to cited text no. 5
    
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Birley JL, Trotter W. Traumatic aneurysms of the intracranial portion of the carotid artery. Brain 1928;51:184-208.  Back to cited text no. 6
    
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Maurer JJ, Mills M, German WJ. Triad of unilateral blindness, orbital fractures and massive epistaxis after head injury. J Neurosurg 1961;18:837-40.  Back to cited text no. 7
    
8.
Grandhi R, Brasiliense LBC, Williamson R, Zwagerman NT, Sauvageau E, Hanel RA. Delayed pipeline embolization of a ruptured true internal carotid artery aneurysm presenting with epistaxis: Case report and review of the literature. World Neurosurg 2019;125:273-6.  Back to cited text no. 8
    
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Renn WH, Rhoton AL Jr. Microsurgical anatomy of the sellar region. J Neurosurg 1975;43:288-98.  Back to cited text no. 9
    
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Kleid MS, Millar HS. Internal carotid artery epistaxis. Otolaryngol Head Neck Surg 1986;94:480-6.  Back to cited text no. 10
    
11.
Singh BP, Metgudmath RB, Singh D, Saxena U. Anatomical variations of sphenoid sinus among patients undergoing computed tomography of paranasal sinus. Int J Otorhinolaryngol Head Neck Surg 2019;5:888.  Back to cited text no. 11
    
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Radkowski D, McGill TJ, Healy GB, Jones DT. Penetrating trauma of the oropharynx in children. Laryngoscope 1993;103:991-4.  Back to cited text no. 12
    
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Cohen JE, Ben-Hur T, Gomori JM, Umansky F, Lylyk P, Rajz G. Stent-assisted arterial reconstruction of traumatic extracranial carotid dissections. Neurol Res 2005;27 Suppl 1:S73-8.  Back to cited text no. 13
    
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Brasiliense LBC, Dumont TM. Alarming internal carotid artery aneurysm eroding the sphenoid sinus. World Neurosurg 2017;108:985.e13-6.  Back to cited text no. 14
    
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Han MH, Sung MW, Chang KH, Min YG, Han DH, Han MC. Traumatic pseudoaneurysm of the intracavernous ICA presenting with massive epistaxis: Imaging diagnosis and endovascular treatment. Laryngoscope 1994;104:370-7.  Back to cited text no. 15
    
16.
Mankahla N, LeFeuvre D, Taylor A. Delayed massive epistaxis from traumatic cavernous carotid false aneurysms: A report of two unusual cases. Interv Neuroradiol 2017;23:387-91.  Back to cited text no. 16
    
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Mizuhashi S, Kohyama S. Endovascular treatment of a small ruptured non-traumatic internal carotid artery aneurysm presenting with repeated massive epistaxis. Interdisciplinary Neurosurgery 2020;(21):100732.  Back to cited text no. 17
    
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Swain SK, Mohapatra SS. A rare and fatal complication of ear syringing: Rupture of pseudoaneurysm at petrous internal carotid artery. Arch Trauma Res 2018;7:166-8.  Back to cited text no. 18
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