PMC5667291_01
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.
AMS2-4-131-g001.jpg
PMC5667291_01_AMS2-4-131-g001.jpg
ams2239-fig-0001
Computed tomography (CT) and CT angiography (CTA) revealed a skull-base fracture extending to the superior wall of the ethmoidal sinus and sella turcica (Fig. 1A-D), and right internal carotid artery (ICA) angiogram illustrated a small irregular-shaped aneurysm (3 mm) at the paraclinoid area (Fig. 1E, F). Following the BOT, internal trapping of the ICA from the proximal site of the origin of the ophthalmic artery to the cavernous portion was carried out using electrical detachable coils (Fig. 1G). Magnetic resonance angiography and positron emission tomography revealed no declines in cerebral blood flow in the ipsilateral hemisphere after 12 months (Fig. 1H, I).
PMC5667291_02
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.
AMS2-4-131-g002.jpg
PMC5667291_02_AMS2-4-131-g002.jpg
ams2239-fig-0002
Computed tomography and CTA revealed a skull-base fracture extending to the lateral wall of the sphenoid sinus and pooling of contrast medium in the sphenoid sinus near the fracture (Fig. 2A-D). Right ICA angiogram revealed an irregular-shaped aneurysm (5 mm to anterior and 7 mm to medial side) at the paraclinoid area (Fig. 2E, F). Then internal trapping from the proximal site of the ophthalmic artery to the petrous portion was carried out on the same day while continuing general anesthesia (Fig. 2G, H). Although the embolization of the distal portion was rather rough because of the irregularity of the injured vessel, complete occlusion of the pseudoaneurysm was confirmed (Fig. 2G). No neurological symptom appeared after the procedure and single-photon emission CT revealed no decline in cerebral blood flow in the ipsilateral hemisphere on the 17th day postoperatively (Fig. 2I).