Left Internal Maxillary Artery Research Articles

Endovascular Management of Intractable Nasopharyngeal Hemorrhage in Patients Irradiated for Nasopharyngeal Carcinoma: A Twelve-Year Experience.

PurposeTo evaluate the efficacy of endovascular treatment of intractable nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and report the relevant endovascular therapeutic experience.Patients and MethodsRecords of patients who underwent endovascular treatment for intractable nasopharyngeal hemorrhage after irradiation for NPC from January 2007 to December 2019 were reviewed. The demographics, endovascular therapeutic details, and clinical outcomes were analyzed.ResultsTwenty-four consecutive patients were included in this study. Nineteen patients underwent embolization of the bilateral internal maxillary arteries; one patient underwent embolization of the right internal maxillary artery and the left external carotid artery; one patient underwent embolization of the left internal maxillary artery and the right internal carotid artery, and the other three patients underwent embolization of the unilateral internal carotid artery. During a mean follow-up of 600.9 days (range, 2–1658 days), twenty patients showed no recurrence of bleeding; one patient died of hemorrhagic shock; one patient had recurrent bleeding, and angiography revealed a pseudoaneurysm in the right internal carotid artery, which was then embolized with spring coil after a 30-min occlusion test. Two patients had recurrent bleeding on 2.5 months and 29.9 months respectively after the endovascular treatment, and angiography showed hypervascularity supplied by the bilateral internal maxillary arteries and then was embolized with polyvinyl alcohol particles. The three patients who received re-interventions showed no re-bleeding until the last follow-up.ConclusionPseudoaneurysm and hypervascularity are the main angiographic characteristics of patients with intractable nasopharyngeal hemorrhage after radiotherapy for NPC, and endovascular treatment provides a safe and effective management approach.

REFRACTORY EPISTAXIS RESULTING IN ISCHEMIC INFARCT

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

Severe facial necrosis in a type 1 diabetic patient secondary to mucormycosis masquerading as an internal maxillary artery occlusion: a case report

BackgroundMucormycosis is a group of rare but life threatening angioinvasive infections caused by fungi of the order Mucorales that often occurs in immunocompromised patients and individuals with poorly controlled diabetes. Rhinocerebral mucormycosis can mimic sinusitis but can rapidly progress to deeper disease and cause facial necrosis. Facial vascular thrombosis is a rare complication of mucormycosis and can confound diagnosis of the disease.Case presentationWe report the case of a 25-year-old female with poorly controlled type 1 diabetes mellitus who initially presented with symptoms of sinusitis but rapidly progressed with signs of left-sided facial necrosis due to occlusion of the left internal maxillary artery. Early surgical debridement did not yield a microbiological diagnosis. Deeper surgical debridements ultimately revealed angioinvasive fungal disease consistent with mucormycosis. The patient recovered after repeated surgical intervention and aggressive parenteral antifungal therapy.ConclusionThis case illustrates an atypical complication of mucormycosis, and emphasizes that a high index of suspicion in vulnerable patient populations aids in the diagnosis of this life-threatening infection.

Clinical and histopathological study of a rare sinonasal glomangiopericytoma: a case report

A 42 year old female patient visited our clinic with reports of a 5 month history of progressive nasal obstruction, associated later with decreased smell sensitivity and left ear block. Routine rhinoscopic and endoscopic examinations revealed a greyish polypoid mass of the left nasal cavity. CT showed a hypervascular mass lesion obliterating the left nasal cavity which was compressing the medial wall of the ipsilateral maxillary sinus. MRI confirmed CT findings of a hypervascular lesion, with MRA identifying the left internal maxillary artery branch as the mainfeeding vessel. Endoscopic surgical excision was performed, with preoperative embolization done prior to excision, to reduce intra-operative blood loss and facilitate complete excision. Histopathology confirmed sinsonasal glomangipericytoma. The patient did not present with any of the known predisposing risk factors and the etiology of the tumor remains unknown. Although it is thought that the incidence of recurrence is low following complete excision, the reported recurrence of 9.5% to 50% necessitates life long follow up.

Multimodality management of a giant skull base hemangioendothelioma of the sphenopetroclival region

A 20-year-old man presented with proptosis, nasal obstruction, vision loss and cavernous sinus syndrome, ongoing for 6years. Imaging and biopsy confirmed a middle skull base epithelioid hemangioendothelioma arising from the left sphenopetroclival region with infratemporal fossa and intracranial-intradural extension into the left temporal lobe. Preoperative embolization of the left internal maxillary artery followed by a combined neurosurgical (front-temporal orbito-zygomatic craniotomy) and otorhinolaryngology (maxillary swing) approach was performed for tumor debulking. Postoperative radiotherapy and maintenance interferon chemotherapy was given to achieve a favorable outcome at 6months follow-up. We describe the pertinent clinical, genetic, radiological and histopathological features, along with the available therapeutic modalities for a primary giant skull base hemangioendothelioma.

Pediatric Facial Arteriovenous Malformations: Case Report and Overview of the Basics

Aims: Describe the multimodality imaging of a large facial AVM in a child and discuss the treatment options of pediatric facial AVMs Case Presentation: An 11 year old girl developed spontaneous (no prior trauma) enlargement of her left cheek with bleeding from her mouth when eating hard foods. The bleeding was described as pulsatile red bleeding that stopped spontaneously. On physical exam, she had a palpable pulsatile left buccal AVM; auscultation revealing high-flow through it. MRI demonstrated a 2.7 cm heterogeneous vascular mass arising in the soft tissues of the left cheek with involvement of the anterior wall of the left maxillary sinus with a large tortuous ectatic draining vein. CTA demonstrated a large AVM involving the left face with the nidus along the posterior wall of the left maxillary sinus, markedly enlarged draining veins throughout the left face/cheek and prominence of the pterygoid venous plexus. Left common carotid artery angiogram demonstrated an extensive AVM centered in the left maxilla. Left external carotid artery angiogram demonstrates the AVM receiving supply from the distal left internal maxillary, left facial, and left internal maxillary arteries. Angiography of the left internal maxillary demonstrated a high flow AVM with drainage to the left facial vein. The left internal maxillary artery was embolized using Onyx. The left facial, transverse facial, and internal

Complete Internal Carotid Artery Occlusion Presenting as “Seizures”

Limb shaking is a rare and atypical presentation for a transient ischemic attack. It can be described as a “cerebral ischemic claudication” due to attenuation in an already compromised cerebral perfusion. The uncharacteristic presentation may lead to confusion and misdiagnosis, for example, focal epilepsy, delaying appropriate therapy. We describe such a case highlighting the clinical implications and options for addressing the underlying cerebrovascular pathology. A 57-years-old female with a 2 weeks history of slurred speech and involuntary shaking of the right upper and lower extremities lasting for a few minutes, which was not associated with loss of consciousness or amourosis fugax. Neuroimaging demonstrated a complete left internal carotid artery occlusion at its origin and a severe focal stenosis of the proximal external carotid artery. Supraclinoidal internal carotid artery was reconstituted via collaterals between ophthalmic artery and branches of left internal maxillary artery. The right internal carotid contributed via the anterior communicating artery. An external carotid endarterectomy was performed, resulting in a complete resolution of her symptoms. In conclusion, limb shaking as a manifestation of carotid occlusion is a rare phenomenon. To prevent misdiagnosis and appropriate treatment, cerebral ischemic claudication must always be considered in the appropriate setup. Any treatment must preserve the collaterals supplying the compromised cerebral vasculature.

High-flow Periorbital Arteriovenous Malformation-A Case Report

Background: Arteriovenous malformations (AVMs) are congenital vascular lesions. They are latent until their expansion was triggered by hormonal changes of puberty or local trauma. The symptoms include pain, ulceration, intermittent bleeding, and obvious esthetic problems. Aim and Objectives: High-flow vascular malformations can expand due to the gradual recruitment of new feeding vessels. Lesions with intolerable symptoms such as pain or significant esthetic disfigurement or signs of impending complications, including enlargement or hemorrhage warrant immediate treatment because these can be signs of progression. Materials and Methods: We report a 50-year-old man without a history of antecedent trauma has had an arteriovenous malformation in the left lower eyelid region for eight years. Angiogram showed the AVM having two main arterial feeders (left internal maxillary artery and ophthalmic artery). The patient underwent preoperative superselective embolization. Sixteen hours later, he had total excision of the vascular lesion. Results: Visual function remained normal postoperatively. Two months later, there were no signs of recurrence. Conclusion: Total resection of the AVM following superselective embolization was curative for the patient presented in the article.

Craniofacial Gunshot Injury Resulting in Pseudoaneurysm of the Left Internal Maxillary Artery and Collet-Sicard Syndrome

Facial gunshot is a challenging medico-surgical emergency because of the complex neurovascular structure in the area. We present a patient who sustained a facial gunshot injury, with massive nasal and oral bleeding that resulted in shock. We review the management of gunshot injury to the internal maxillary artery, both in acute and chronic stages. In addition, we describe the clinical course of the rarely occurring Collet-Sicard syndrome, which involves injury to the 9th, 10th, 11th, and 12th cranial nerves associated with gunshot injury.

Orbital exenteration after transarterial embolization in a patient with Wyburn-Mason syndrome: Pathological findings

We present the pathological findings at orbital exenteration in a patient with Wyburn-Mason syndrome who underwent transarterial embolization. A 31-year-old man with a 10-year history of gradual exacerbation of left exophthalmos and left cheek swelling was found to have facial and orbital arteriovenous malformations on the left side. There was no vascular malformation in the brain. The feeding arteries derived from the left internal maxillary artery, facial artery, and ophthalmic artery. He underwent several courses of transarterial embolization of the feeding arteries from the left internal maxillary artery and then from the facial artery, resulting in no reduction of the arteriovenous malformation. He finally elected to undergo ophthalmic artery embolization in the expectation of a reduction and with the understanding that he would lose sight in his left eye. Two years later, he requested lid-sparing orbital exenteration and reconstruction with cutaneous flap transfer and prosthesis for cosmetic reasons. Pathologically, orbital vascular channels of varying sizes were filled with embolizing glue and had degenerating vascular wall cells surrounded by inflammatory cell infiltration. The central retinal artery in the optic nerve was also filled with the embolizing glue, and the retina lost the ganglion cell layer and inner nuclear layer but maintained the outer nuclear layer and outer segments. Marked anastomoses and hence incomplete embolization among the feeding arteries of facial and orbital vascular malformations in Wyburn-Mason syndrome do not respond well to attempts at feeding vessel embolization, which result in unsuccessful closure of the malformation.

Infantile schwannoma of the maxillary sinus

A rare case of a 5-year-old female with schwannoma of the maxillary sinus is presented. She had complained of painless swelling of the left cheek and hard palate for a duration of one year. Preoperatively, a CT scan strongly suggested it to be a maxillary cyst with an erupted tooth rather than neoplasm. The tumour was completely removed after embolization of the left internal maxillary artery. The tumour was composed of spindle cells in a palisading pattern and intercellular collagenous fibres. Mitotic figures and atypical nuclei were not observed. Immunohistochemically, the majority of the cells were positive for NSE and S-100 protein, whereas GFA and PCNA showed little immunoreaction. The pathological diagnosis was Antony type A of schwannoma arising in the maxillary sinus.

Central Retinal and Posterior Ciliary Artery Occlusion after Particle Embolization of the External Carotid Artery System

A 15-year-old boy underwent neuroradiologic embolization of the left internal maxillary artery with polyvinyl alcohol to stop traumatic epistaxis after failure of surgical clipping and nasal packing. Selective catheterization of the external carotid artery before embolization showed a faint choroidal blush. Although the procedure provided hemostasis, embolization to the central retinal artery and Ciliary arteries resulted in loss of vision. The route of the emboli to the eye was via the anastomotic network of the lacrimal artery supplied by the external carotid artery system. Neuroradiologic embolization of the external carotid artery is an effective mode of therapy for dural-cavernous fistulas when fed by the external carotid artery system. Because the blood flow to the brain and eye is predominantly supplied by the internal carotid artery, embolization of the external carotid artery is considered relatively safe. The authors document the importance of recognition of the choroidal blush during selective external carotid artery angiography as a sign of collateral blood flow to the eye. Physicians and patients need to be aware of the risk of blindness as a complication of external carotid artery embolization when this sign is present.