Case report
A 67-year-old woman, who has been followed up for osteonecrosis of the
sphenoid bone, right blindness, and hypopituitarism by our department in
the last 3 years after multidisciplinary treatment of a pituitary tumor
20 years ago, presented with massive epistaxis. She had undergone two
transsphenoidal microsurgeries and craniotomy for pituitary adenoma, as
well as radiation therapy including cobalt brachytherapy and gamma
knife. On the day before her presentation at our hospital, a brief loss
of consciousness was observed due to a sudden massive epistaxis that
fortunately spontaneously stopped. An otorhinolaryngologist, who had
followed her up due to osteonecrosis, especially the bone around the C3
segment of the right ICA that disappeared after chronic infection for 3
years (Figure 1A, B), considered a possibility of right ICA rupture due
to her episode of massive epistaxis. Therefore, he consulted with
neurosurgeons to evaluate the source of epistaxis. While waiting for the
neurosurgeons, a massive epistaxis suddenly occurred again with loss of
consciousness. Accordingly, the otorhinolaryngologist urgently attempted
to stop bleeding using total nasal packing with a balloon catheter and
impregnated ointment gauze. However, epistaxis continued despite the
procedure and fortunately stopped spontaneously within a few minutes
(Figure 2A). Although the neurosurgeons performed conventional
angiography, no noticeable findings were found in the right ICA (Figure
2B). Therefore, the neurosurgeons and otorhinolaryngologists first
suggested that one of the peripheral branches of the right external
carotid artery (ECA) was the source. Therefore, the neurosurgeon
occluded the right sphenopalatine artery from which contrast medium
appeared to leak slightly. The patient was admitted to the neurosurgical
department with a generous cooperation of the otorhinolaryngologist
performing blood transfusion and strict follow-up, in addition to
suggesting ICA rupture.
After admission, massive epistaxis suddenly occurred again despite right
sphenopalatine artery occlusion. Therefore, a high-flow bypass between
the second segment of the right middle cerebral artery (MCA) and the
right cervical ECA was urgently performed. This procedure comprised
using radial artery (RA) graft, surgical trapping of the right ICA, and
skull base reconstruction with a pedicle mucosal flap harvested from the
left nasal floor accompanied by removal of necrotic tissue. First, a RA
graft was sutured to the second segment of the right MCA end-to-side by
interrupted suture and the right cervical ECA end-to-side by continuous
suture. The ophthalmic segment of the right ICA was ligated using a
clip, and the cervical segment was ligated. Thereafter, the
otorhinolaryngologist endoscopically removed necrotic tissues on the
sphenoidal bone without any damage to the dura mater and then covered
the skull base and sphenoid sinus with a vascular pedicled nasomucosal
flap harvested from the left nasal floor.
No postoperative epistaxis was observed. Although small watershed
infarcts of the right hemisphere were observed, left paresis was
transient after surgery. The patient was discharged one month after
surgery without any residual disability. Revascularization was
successful, and there was no evidence of decreased blood flow on
single-photon emission computed tomography (Figure 3A, B). Additionally,
chronic infection of the sphenoid bone improved (Figure 1C, D). She has
been uneventful for 15 months after surgery.