Maxillary Artery Research Articles

Endoscope-Assisted Pedicled Maxillary Artery to Middle Cerebral Artery Bypass: An Anatomic Feasibility Study.

Extracranial to intracranial bypass is used to augment and/or replace the intracranial circulation for various pathologies. The superficial temporal artery is the mainstay donor for pedicled bypasses to the anterior circulation but can be limited by its variable size, low native flow rates, and potential scalp complications. Interposition grafts such as the radial artery or greater saphenous vein are alternatives but are sometimes limited by size mismatch, length needed to reach the extracranial circulation, and loss of inherent vascular elasticity. Interposition grafts between the maxillary artery (IMA) and middle cerebral artery (MCA) address these limitations. To explore the feasibility of harvesting the IMA through an endoscopic transnasal, transmaxillary approach to perform a direct IMA to MCA bypass. Combined transcranial and endoscopic endonasal dissections were performed in embalmed human cadavers to harvest the IMAs for intracranial transposition and direct anastomosis to the MCA. Donor and recipient vessel calibers were measured and recorded. A total of 8 procedures were performed using the largest and distal-most branches of the IMA (the sphenopalatine branch and the descending palatine branch) as pedicled conduits to second division of middle cerebral artery (M2) recipients. The mean diameter of the IMA donors was 1.89 mm (SD ± 0.42 mm), and the mean diameter of the recipient M2 vessels was 1.90 mm (SD ± 0.46 mm). Endoscopic harvest of the IMA using a transnasal, transmaxillary approach is a technically feasible option offering an excellent size match to the M2 divisions of the MCA and the advantages of a relatively short, pedicled donor vessel.

Head arteries of the red squirrel (Sciurus vulgaris)

The red squirrel (Sciurus vulgaris) is a medium-sized rodent protected in most of Europe. The present study aimed to investigate and describe the arterial vascularization of the head of the adult red squirrel. In the study, 48 specimens of adult red squirrels were used. The first preparation method used in the study was corrosion casting using a stained solution of the chemo-setting acrylic material injected into bilateral common carotid arteries resulting in corrosion castings of the vessels on a bone scaffold. The second method was injecting liquid-stained latex into both common carotid arteries. It resulted in a stained arterial vessel on fixed soft tissue preparations. The main vessels providing blood to the head were paired with common carotid arteries that divide into external and internal carotid arteries. The internal carotid artery passes into the stapedial artery. After giving its branches, the stapedial artery exits the cranial cavity through the sphenofrontal foramen and enters the orbit. The suborbital and the mandibular regions were supplied by the maxillary artery, linguofacial trunk, and their branches. Description of the detailed anatomy of the head arteries in red squirrels may contribute to establishing diagnostic and treatment protocols for wildlife rehabilitation centers, which may be crucial since red squirrels are endangered by the spreading of invasive Eastern gray squirrels (Sciurus carolinensis) in Europe. It may also contribute to veterinary care for other members of the Sciuridae family kept as pets.

Initial Experience of Intra-Arterial Chemotherapy Using a Novel External Carotid Arterial Sheath System Combined with Radiotherapy and Systemic Chemotherapy for Locally Advanced Tongue Cancer.

We retrospectively evaluated the safety and effectiveness of an external carotid arterial sheath (ECAS) for intra-arterial chemotherapy (IACT) for locally advanced tongue cancer. Thirty-one patients with the Union for International Cancer Control's 8th TNM stage III-IV tongue cancer underwent IACT using the ECAS combined with RT and systemic chemotherapy with either cisplatin and fluorouracil (FP) or docetaxel, cisplatin, and fluorouracil (TPF) between October 2015 and February 2021. The ECAS was inserted retrogradely via the superficial temporal artery, and the tip was placed in the external carotid artery between the maxillary and facial arteries. A microcatheter was inserted into each tumor-feeding artery through the ECAS under fluoroscopy, wherein cisplatin 50 mg/m2 was administered. IACT was performed weekly with neutralization using sodium thiosulfate. Complete response of the primary lesion was achieved in 28/31 (90%) patients. The median follow-up for all patients was 39 months. The 3-year overall survival, progression-free survival, and local control rates were 81.6%, 74.2%, and 83.4%, respectively. Grade 3 and greater toxicities included oral mucositis (45%), neutropenia (39%), nausea (13%), anemia (10%), thrombocytopenia (10%), dry mouth (10%), and fever (3%). There were no severe complications associated with IACT. In conclusion, the ECAS is feasible and effective for locally advanced tongue cancer.

Radiological analysis of maxillary artery relationships to key bony landmarks in maxillofacial surgery

The maxillary artery (MA) is a key structure at risk of injury in numerous oral and maxillofacial surgical (OMS) procedures. Knowledge of safe distances from this vessel to surgically familiar bony landmarks could improve patient safety and prevent catastrophic haemorrhage. Distances between the MA and bony landmarks on the maxilla and mandible were measured using CT angiograms on 100 patients (200 facial halves). The vertical height of the pterygomaxillary junction (PMJ) was mean (SD) measurement of 16 (3) mm. The MA enters the pterygomaxillary fissure (PMF) a mean (SD) distance of 29 (3) mm from the most inferior point of the PMJ. The mean (SD) shortest distance between the MA and medial surface of the mandible was 2 (2) mm (with the vessel directly contacting the mandible in 17% of cases). The branchpoint (bifurcation of the superficial temporal artery (STA) and MA) was directly in contact with the mandible in 5% of cases. The mean (SD) distances between this bifurcation point and the medial pole of the condyle were 20 (5) mm and 22 (5) mm, respectively. A horizontal plane through the sigmoid notch perpendicular to the posterior border of the mandible is a good approximation of the trajectory of the MA. The branchpoint is usually within 5 mm of this line and inferior in 70% of cases. Surgeons should take note that both the branchpoint and the MA contact the surface of the mandible in a significant number of cases.

Ultrasound parameters associated with stroke in patients with moyamoya disease: a logistic regression analysis

BackgroundMoyamoya disease can lead to stroke with devastating consequences, it is necessary to find a non-invasive and effective approach to identify the occurrence of stroke. In this study, we aim to analyze the association between ultrasound parameters and ipsilateral cerebral hemisphere stroke in patients with moyamoya disease by logistic regression analysis.MethodsIn this retrospective case–control study, 88 patients with MMD (153 cerebral hemispheres) hospitalized in Beijing Tiantan Hospital, Capital Medical University from November 2020 to October 2021 were analyzed. According to the occurrence of stroke, the 153 cerebral hemispheres were divided into a stroke group and a non-stroke group. Clinical data and ultrasound parameters of the ipsilateral internal carotid artery, superficial temporal artery, maxillary artery, and posterior cerebral artery were recorded. The ultrasound parameters were divided into four groups according to interquartile range, and then they were compared between the stroke group and the non-stroke group. Those with significant differences were scored by multivariate logistic regression analysis.ResultsThere were 75 cerebral hemispheres (49.0%) in the stroke group and 78 cerebral hemispheres (51.0%) in the non-stroke group. Logistic regression analysis showed that the internal diameter of the internal carotid artery, peak systolic velocity of the internal carotid artery and peak systolic velocity of the posterior cerebral artery were independently correlated factors for stroke in patients with MMD. The fourth quartile group of the above three ultrasound parameters was taken as the reference group, and the odds ratio of the first quartile group were 11.679 (95% CI 2.918–46.749, P = 0.001), 19.594 (95% CI 4.973–77.193, P < 0.001), and 11.657 (95% CI 3.221–42.186, P < 0.001), respectively.ConclusionUltrasound parameters are independently correlated with ipsilateral cerebral stroke in patients with MMD. Ultrasound provides a new way to identify stroke in MMD patients. Future prospective cohort studies are needed to verify the clinical value of ultrasound in identifying patients with MMD at high risk of stroke.

Soluble epoxide hydrolase inhibitor, t-AUCB, improves salivary gland function by ameliorating endothelial injury

AimsInhibitor of soluble epoxide hydrolase (t-AUCB) has been used in the experimental therapy of hypertension. This study aimed to investigate whether the secretion of submandibular glands (SMGs) altered in renal hypertensive rats, and to explore whether t-AUCB could improve the salivary secretion. Main methods2-kidney 1-clip Sprague-Dawley rats were used as renal hypertensive animals. t-AUCB treatment was given for 1 week after 8 weeks modeling. Blood pressure, blood perfusion and the secretion of SMGs, and endothelium-dependent relaxation of external maxillary artery were measured to investigate the effects of t-AUCB on the vascular tone and the secretion of SMGs in renal hypertensive rats. SMGs were collected for histological evaluation and the internal arteries were dissected for primary endothelial cells culture. Key findingsThe blood perfusion and flow rate of SMGs in the renal hypertensive rats were significantly lower than those in the controls. Endothelium-dependent relaxation of the external maxillary artery and AMPK/Akt/eNOS signaling was impaired in hypertensive rats. The glandular morphology and the concentration of salivary ions did not change obviously. t-AUCB treatment ameliorated the secretion of SMGs, the blood perfusion, and the dysfunction of endothelium-dependent relaxation of the external maxillary artery by activating the AMPK/Akt/eNOS pathway in hypertensive rats. Significancet-AUCB increases the blood perfusion through ameliorating dysfunction of endothelium-dependent relaxation of SMGs arteries and thus improves the hyposecretion of SMGs in hypertensive rats.

A case of intraoperative observation of maxillary artery aneurysm

The maxillary artery aneurysm occurs rarely, only a few cases were described in the foreign literature where the aneurysm were associated mainly with the past head injury. The behavior of the aneurysm is largely unknown: both spontaneous resolution and growth of the aneurysm, resulting in rupture, have been reported.&#x0D; We observed an aneurysm of the maxillary artery in the maxillary sinus as an intraoperative finding, with the following bleeding and embolization of the bleeding vessel.&#x0D; Due to the growing number of endovideoscopic operations on the axillary system, it was proposed to increase the volume of preoperative examination to prevent the intraoperative bleeding.

The Head and Neck Vascular Anatomical Variability in the Laboratory Rat and its Significance to Medical Science

Abstract Laboratory rats are often used in experimental research of concern to human and veterinary medicine. There are several advantages of using rats as a scientific medium. In this study rats will be used as the scientific model as, previously discussed, they have proven their effectiveness in cardiovascular studies. The aim is to give a description of the cranial region, the head and neck of the rat as well as imaging of the vasculature of these regions to support the planning of surgical therapeutic methods to be applied to human and veterinary medical research. The research of the blood vessels morphology in anatomical studies is key to the prevention of ischemia during organ surgery. In recent times the laboratory rat has become one of the most popular models for experiments in medical research. Corrosion casts were prepared on the cranial arteries of the body of 20 adult Wistar rats using Duracryl Dental® and PUR SP as the casting medium. We found the absence of the brachiocephalic trunk in some cases. Thyroid arteries originated independently or by the short common trunk from the right and left common carotid artery. The facial artery originated by the short trunk with the maxillary artery, or by the linguofacial trunk with the lingual artery from the common carotid artery. The results of this study revealed that, the functional anatomical relationship between the rat neck and head structures are important for the development of medical research of concern to human and veterinary experimental medicine.

Evaluation of an in vivo preclinical model for human middle meningeal artery embolization using the posterior intercostal artery of the swine

BackgroundEmbolization of the middle meningeal artery (MMA) is a promising minimally invasive technique that is gaining traction in the treatment of chronic subdural hematoma. Unfortunately, the human meninges and associated...

Relationship of the neurovascular structures of the infratemporal fossae in black Zimbabweans: A cadaveric study

The Maxillary Artery (MA) is known to vary in its relationship to lateral pterygoid muscle (LPM) and its relationship to inferior alveolar nerve (IAN) and lingual nerve (LN). The variation poses surgical challenges and complications in anesthetic injection. This cadaveric study sought to describe the anatomy of the inferior alveolar nerve, lingual nerve and maxillary artery in infratemporal fossa and its associated variations. Thirty hemi- sections from 15 male cadavers were used. Dissection of the infratemporal fossae was done to expose the MA, LPM, IAN and LN. The relationship of MA to LPM was noted, roots of IAN were noted and relationship of structures were scrutinized. Pictures were taken for further analysis. Out of 30 hemi-sections, dissected 43.3% had a medial relationship to LPM while 56.7% of MA had a lateral relationship. Three (20%) of the cadavers showed asymmetry whereby MA passed on the medial side of LPM on one side while the other side it passed on the lateral aspect. Most of the hemi- sections (86.7%) had IAN originating with one (1) root, 3 hemi-sections (10%) with two roots and one (3.3%) with three roots. Only one hemi-section showed presence of a communicating branch between IAN and LN. The variations in MA in this population displays patterns comparable to other populations. There was high prevalence of MA passing lateral to LPM, which is consistent with studies done elsewhere. There were variations of IAN originating with multiple roots and presence of communicating branch between IAN and LN, which was consistent with case reports in literature.

Letter to the Editor: “Can I Afford to Become a Neurosurgeon in the United Kingdom in the Current Atmosphere?”

Cerebral revascularization strategies through extracranial to intracranial bypass have been adopted in the management of complex intracranial aneurysms. The internal maxillary artery used as a donor in a bypass is an effective method. At present, there are few quantitative analyses of cerebral blood flow perfusion. The main focus of this study was to evaluate the effectiveness of blood perfusion after bypass grafting.From April 2015 to December 2017, 19 patients who underwent internal maxillary artery radial artery middle cerebral artery bypass surgery with unobstructed bypass vessels were selected. Cerebral blood flow perfusion before and after bypass surgery was quantitatively evaluated by computed tomography perfusion imaging. The cerebral blood perfusion in the region of interest was measured by computed tomography perfusion.The aneurysms were excised after trapping in 2 cases with mass effects and neural compression. Proximal occlusion of the parent artery was performed in 9 cases of fusiform or giant dissecting aneurysms. Trapping was performed after bypass surgery in 8 cases. Within 3 months after surgery, 17 patients had good outcomes. After the hypothesis test, there was a significant difference between the preoperative △cerebral blood volume and postoperative △cerebral blood volume in the anterior area of the semioval center cross section (P = 0.001 < 0.05).The internal maxillary artery as a bypass donor is an effective method that can provide sufficient intracranial blood perfusion, and there is usually no cerebral ischemia in the surrounding area.

Letter to the Editor Regarding “Burnout Among Neurosurgeons and Residents in Neurosurgery: A Systematic Review and Meta-Analysis of the Literature”

Cerebral revascularization strategies through extracranial to intracranial bypass have been adopted in the management of complex intracranial aneurysms. The internal maxillary artery used as a donor in a bypass is an effective method. At present, there are few quantitative analyses of cerebral blood flow perfusion. The main focus of this study was to evaluate the effectiveness of blood perfusion after bypass grafting.From April 2015 to December 2017, 19 patients who underwent internal maxillary artery radial artery middle cerebral artery bypass surgery with unobstructed bypass vessels were selected. Cerebral blood flow perfusion before and after bypass surgery was quantitatively evaluated by computed tomography perfusion imaging. The cerebral blood perfusion in the region of interest was measured by computed tomography perfusion.The aneurysms were excised after trapping in 2 cases with mass effects and neural compression. Proximal occlusion of the parent artery was performed in 9 cases of fusiform or giant dissecting aneurysms. Trapping was performed after bypass surgery in 8 cases. Within 3 months after surgery, 17 patients had good outcomes. After the hypothesis test, there was a significant difference between the preoperative △cerebral blood volume and postoperative △cerebral blood volume in the anterior area of the semioval center cross section (P = 0.001 < 0.05).The internal maxillary artery as a bypass donor is an effective method that can provide sufficient intracranial blood perfusion, and there is usually no cerebral ischemia in the surrounding area.

Ultrasonographic evaluation of the effect of splint therapy on masseter muscle and blood flow in patients with bruxism.

To investigate the effect of splint therapy on masseter muscle and blood flow in patients with bruxism using ultrasonography (USG). Twenty female patients with bruxism receiving splint treatment were studied. Masseter thickness and elasticity were assessed using gray-scale USG and shear-wave elastography (kPa) at rest and maximum clenching. Blood flow parameters of external carotid artery (ECA), maxillary, facial, mental artery were examined using Doppler USG before and after splint application. Thickness and elasticity of masseter muscle was statistically significantly decreased at rest after splint therapy (p < 0.05). Significant difference was determined only in some parameters of ECA and maxillary artery in Doppler USG before and after splint (p < 0.05); there was no difference for facial and mental artery (p > 0.05). Thickness and elasticity of masseter muscle were significantly decreased after splint therapy. USG can measure muscle activity and blood flow in bruxism patients.

Efficacy of endovascular superselective chemoembolization with HepaSphere 50–100 μm microspheres saturated with cytostatic in stopping nosebleeds in patients with nasopharyngeal cancer

The OBJECTIVE was to show the effectiveness of a new method for stopping nosebleeds in patients with nasopharyngeal cancer using endovascular superselective chemoembolization of the tumor arterial bed with HepaSphere 50–100 μm microspheres saturated with the cytostatic doxorubicin.METHODS AND MATERIALS. The results of treatment of 94 patients who against the background of progressive growth of nasopharyngeal cancer and ongoing combined treatment in oncology centers experienced nosebleeds are presented. In all these patients, according to the results of examinations in cancer centers, no convincing source of nosebleeds was identified. In the conditions of Polenov Neurosurgical Institute, 94 patients underwent endovascular superselective chemoembolization of the vasculature of nasopharyngeal cancer. The embolizate was a mixture of HepaSphere 50–100 μm microspheres saturated with the cytostatic doxorubicin (50 mg). All patients were included in the study in the absence of contraindications and after signing a voluntary informed consent approved by the ethics committee. The selection of patients was carried out according to the following criteria: thorough morphological verification of the neoplasm; locally advanced process of III and IV stages (T2-4 N0-2M0); no history of other cancers; absence of individual hematogenous metastases; absence of competitive pathology in the stage of decompensation; age was over 18 years old. All patients underwent induction-simultaneous chemoradiotherapy (CRT) with the use of radiation therapy in the usual dose fractionation regimen.RESULTS. The hemostatic effect was achieved in all 94 patients due to sequential superselective chemoembolization of the vasculature of the tumor itself with embolizate, which was a mixture of HepaSphere 50–100 μm microspheres saturated with the cytostatic doxorubicin (50mg). In the future, nosebleeds in these patients did not occur. The main sources of nosebleeds were the following branches of the external carotid artery: in 46.2 % of cases – the maxillary artery, in 37.6 % – the ascending pharyngeal artery, in 8.6 % – the occipital artery, in 5.4 % – the artery of the carotid node, in 2.2 % – other branches of the external and internal carotid arteries on one side or on both sides.CONCLUSION. The method of endovascular superselective chemoembolization with doxorubicin of the vasculature of nasopharyngeal cancer complicated by nosebleeds developed and introduced into medical practice was the initial stage of the combined treatment of these neoplasms. A good hemostatic effect was achieved in all 94 patients.

Study of Branching Pattern of External Carotid Artery

Background: Anatomical information of vasculature is of need for the surgeons and radiologists. Carotid artery and its branches supply most of head, neck, and brain. Injuries to the external carotid artery and its branches is often complex and results in high mortality. Knowledge of types and frequencies of vascular variations of external carotid artery is of help for invasive diagnostic and interventional procedures. Materials and methods: 50 external carotid arteries were dissected to study the branching pattern of external carotid artery. Results: Conventional branching pattern was seen in 58% specimens. Superior thyroid artery originated from common carotid artery in 12% specimens. Linguofacial trunk was observed in 16%. Occipital artery and ascending pharyngeal artery rose from a single trunk in 12%. Origin of facial artery from maxillary artery was observed in one specimen. Conclusion: Study of variations in the branching pattern of the external carotid artery adds to the existing anatomical knowledge. Variations in the branching pattern is of definite help for interventional radiologists, vascular, craniofacial and neck surgeons. KEY WORDS: External carotid artery, Facial artery, Linguofacial trunk.

Endoscopic Management of Sinonasal Vascular Tumors Without Embolization: Our Experience with Vessel Ligation

ABSTRACT Objective: To present our surgical experience and technique in performing endoscopic sinus surgery for vascular sinonasal tumors without pre-operative embolization using intraoperative ligation of the external carotid artery or its distal branches. Methods: Design: Retrospective Series Setting: Tertiary Private Teaching Hospital Participants: Seven Patients Results: Out of 7 patients (5 males, 2 females, aged 12 to 64 years old) with non-embolized vascular sinonasal tumors, 2 had juvenile angiofibroma, 3 had a benign vascular tumor (hemangiopericytoma, hemangioma and a vasoformative solitary fibrous tumor), and 2 had a malignancy (rhabdomyosarcoma, squamous cell carcinoma). Four (57.1%) had external carotid artery ligation, two (28.6%) had internal maxillary artery ligation and one (14.2%) had sphenopalatine artery ligation. The mean intraoperative blood loss was 2447.1 mL (range 900mL to 5,000mL) and average operation duration was 7.6 hours (range 2.9 hours to 14.5 hours). The average amount of transfused blood products was 1785.7mL (zero to 3,000mL). The average hospital stay was 7 days (range 2 to 13 days) with one post-operative complication (ICU admission for hypotension from intraoperative blood loss). Conclusion: Intraoperative ligation of the ECA or its distal branches to disrupt the vascular supply of sinonasal tumors may provide a viable means of preventing excessive intraoperative blood loss in patients with non-embolized vascular sinonasal tumors.

Computed Tomography Perfusion Imaging Study of Intracranial Complex Aneurysms Treated by Internal Maxillary Artery Bypass Grafting

Cerebral revascularization strategies through extracranial to intracranial bypass have been adopted in the management of complex intracranial aneurysms. The internal maxillary artery used as a donor in a bypass is an effective method. At present, there are few quantitative analyses of cerebral blood flow perfusion. The main focus of this study was to evaluate the effectiveness of blood perfusion after bypass grafting. From April 2015 to December 2017, 19 patients who underwent internal maxillary artery radial artery middle cerebral artery bypass surgery with unobstructed bypass vessels were selected. Cerebral blood flow perfusion before and after bypass surgery was quantitatively evaluated by computed tomography perfusion imaging. The cerebral blood perfusion in the region of interest was measured by computed tomography perfusion. The aneurysms were excised after trapping in 2 cases with mass effects and neural compression. Proximal occlusion of the parent artery was performed in 9 cases of fusiform or giant dissecting aneurysms. Trapping was performed after bypass surgery in 8 cases. Within 3months after surgery, 17 patients had good outcomes. After the hypothesis test, there was a significant difference between the preoperative △cerebral blood volume and postoperative △cerebral blood volume in the anterior area of the semioval center cross section (P=0.001<0.05). The internal maxillary artery as a bypass donor is an effective method that can provide sufficient intracranial blood perfusion, and there is usually no cerebral ischemia in the surrounding area.

Botulinum toxin injections in jaw-opening dystonia. The lateral pterygoid – maxillary artery problem

It has been suggested that the variations in the trajectory of the maxillary artery (MA) near the lateral pterygoid muscle (LPM) play a critical role in Botulinum neurotoxin (BoNT) injections in patients with jaw-opening/deviation dystonia (JOD). In the case of a lateral course to the LPM, an extraoral injection entails risks of MA injury, pain, and hematoma. Previous reports suggest geographical differences in variations of the MA-LPM relationship. We aimed to determine these variations in Turkish individuals and highlight the need to establish a consensus on approach to LPM injections. In 284 individuals, contrast-enhanced magnetic resonance angiography (MRA) images were evaluated by two radiologists on both sides for the variations in the course of the MA in the infratemporal fossa. Images of 44 were excluded due to trauma, arteriovenous malformation, mass, surgery, and imaging artifacts. Of the included, 62.1% were female. In 480 evaluations of 240 individuals, the MA passed lateral to the LPM in 65.6% (n = 315). No sex difference was noted. In 51 individuals (21.3%), the MA course differed on the right and left sides (medial–lateral asymmetry). These results confirm that the lateral course of the MA is more frequent. In patients with JOD, the trajectory of the MA should be determined with imaging prior to extraoral BoNT injections. In the case of a lateral course, an intraoral approach seems to be safer to avoid a potential MA injury.

Resection Via Transpalatal Approach of Huge Solitary Fibrous Tumor Involving Pterygopalatine Fossa

Solitary fibrous tumors (SFTs) are spindle-cell tumors that rarely arise within extrathoracic area. Massive SFTs involving the pterygopalatine fossa are extremely rare and surgical excision represents a multidisciplinary surgical challenge. We present a case of 64-year-old female with a huge mass originating from the pterygopalatine fossa invading the skull base. Distinct microscopic findings and a positive nuclear staining of signal transducer and activator of transcription 6 (STAT-6) pathologically confirmed SFT. The right internal maxillary artery branch was embolized preoperatively and a surgical excision was performed through a combined technique of transpalatal, mid-facial degloving and endoscopic approach. Postoperative radiotherapy successfully removed the remnant tumor adjacent to the carvenous sinus. Follow- up MR images showed no evidence of recurrence for two years. To our knowledge, there has been no previous report of the successful treatment of this vast extent of SFT in the pterygopalatine region via endoscopic-external-combined approach and radiotherapy.

MANAGEMENT OF MASSIVE BLEED IN A POST-OPERATIVE CASE OF JUVENILE ANGIOFIBROMA

The nasopharyngeal angiobroma is a very aggressive, vascular tumor that may represent a challenge for the anesthesiologist due to the risk of profuse bleeding. We report the case of a 20 years old, 50 kg, ASA1 patient, who was scheduled for bleeding during nasal packing. Mallampati 2, previous successful intubation reported. Induction was done with propofol, fentanyl, lidocaine and atracurium, followed by intubation by direct laryngoscopy. Sevourane and nitrous were used for maintenance. Central venous access and arterial catheterization were provided. Massive bleeding required intensive volemic resuscitation and hemotransfusion. The maxillary artery was ligated by surgeon. During the whole procedure, the patient received 2000 ml of ringer lactate, 1000ml of hydroxyethyl starch, 4 units PCV, 4 units FFP and 4 units platelet units. Serial arterial blood gas analysis revealed Hb = 6g/dL and pH was physiological all the time. Noradrenaline infusion started and titrated according to BP. The total duration of the procedure was 5 hours. The patient was sent to the ICU intubated in view of massive blood loss and airway edema for elective ventilation.