REFRACTORY EPISTAXIS RESULTING IN ISCHEMIC INFARCT

Abstract

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Patients on dual-antiplatelet therapy (DAPT) have a 5% risk of major bleed within the first year (1). Epistaxis is common in the adult population and patients on DAPT have a higher risk of developing refractory epistaxis (2). CASE PRESENTATION: A 93-year-old Caucasian male, with past medical history of coronary artery disease treated with percutaneous coronary intervention (PCI) with drug-eluding stent 3 months prior to admission, presented with recurrent episodes of epistaxis. He was on DAPT for recent stent placement. His refractory epistaxis was thought to be secondary to his DAPT; therefore, clopidogrel was discontinued. He underwent repeat packing of bilateral nares but continued to bleed and became hypotensive and anemic with hemoglobin of 6.4. He was transfused 4 units of packed red blood cells and emergently underwent left internal maxillary artery embolization with angiography and preoperative intubation for airway protection. Once the patient was weaned off sedation about 5 hours postoperatively, the patient was found to have new right upper extremity weakness. Brain magnetic resonance imaging (MRI) showed acute infarcts throughout the left cerebral hemisphere and the lentiform nucleus in an embolic pattern. He was outside the window for tissue plasminogen activator. Surface cardiac echocardiography was not suggestive of a cardioembolic source. Neurological exam revealed that the patient did not follow commands, and did not withdraw to pain in his right upper extremity. The prognosis was not consistent with the patient’s goals, so his family decided to shift their goals to provide comfort care. DISCUSSION: Our patient presented with intractable epistaxis while on DAPT for multiple cardiac stents. Serious adverse effects of transarterial embolization include monocular blindness, peripheral facial nerve paralysis, cerebral infarction, and ischemic sialadenitis. These adverse effects are relatively rare, occurring in up to 2% of cases, and result from inadvertent embolization of the internal carotid artery or the ophthalmic artery (3). In our patient, embolization of the internal carotid artery likely occurred due to manipulation of an atherosclerotic artery causing diffuse embolization of plaque into the left cerebral hemisphere. Our patient underwent PCI a few months prior to admission for chronic stable angina. Additionally, he had previously been on clopidogrel, which had been discontinued due to gastrointestinal bleeding. Given the patient’s significant risk factors and mild symptoms, his most recent PCI was likely unnecessary and led to bleeding and an emergent procedure, which resulted in significant neurologic deficits. CONCLUSIONS: Our patient underwent a likely unnecessary PCI for chronic stable angina, which led to refractory epistaxis and ultimately an ischemic infarct. Risk stratification for PCI is an important tool which could have prevented our patient’s outcome. Reference #1: Gimbel ME, Minderhoud SCS, Ten Berg JM. A practical guide on how to handle patients with bleeding events while on oral antithrombotic treatment. Neth Heart J. 2018;26(6):341–351. Reference #2: Petruson B, Rudin R. The frequency of epistaxis in a male population sample. Rhinology 1975; 13:129. Reference #3: Willems PW, Farb RI, Agid R. Endovascular treatment of epistaxis. AJNR Am J Neuroradiol. 2009 Oct;30(9):1637-45. DISCLOSURES: No relevant relationships by Nelly Bellamy, source=Web Response Speaker/Speaker's Bureau relationship with Theravance Please note: $1001 - $5000 Added 06/12/2020 by Edward Charbek, source=Web Response, value=Honoraria No relevant relationships by Joseph Cumming, source=Admin input No relevant relationships by Abigail Go, source=Web Response