Abstract
Background and objectiveTo 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.MethodsWe 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.ResultsNo 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.ConclusionsAlthough 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.
Highlights
The internal carotid artery (ICA) acute bleeding is one of the most serious neurovascular emergencies that require rapid diagnostic framing and therapeutic targeting
The aim of this study is to describe our single-center experience in the management and treatment of acute cavernous ICA bleeding with flow diverter stent (FDS) endovascular emergency placement, as an isolated procedure or a combined technique with an endoscopic endonasal trans-sphenoidal cavernous ICA wall reconstruction, providing indications, contraindications, and outcomes
No thromboembolic cerebral ischemic complications occurred after positioning the stent in any patient
Summary
The internal carotid artery (ICA) acute bleeding is one of the most serious neurovascular emergencies that require rapid diagnostic framing and therapeutic targeting. Among the causes of ICA acute injury are traumatic damage, iatrogenic procedure, and neoplastic invasion. Among the carotid segments of the most difficult management in the case of acute rupture is the cavernous tract. In the case of cavernous ICA acute injury, the control of bleeding can be obtained using an endovascular procedure, endonasal endoscopic approach, or combined techniques [1,2,3,4,5,6]. 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
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