Pseudoaneurysm of the internal maxillary artery and Frey's syndrome after blunt facial trauma

Traumatic Pseudoaneurysm Arising From Proximal Facial Artery: A Case Report and Literature Review

Pseudoaneurysms of facial artery usually arise from the distal part of the vessel. Only 4 cases were described in the literature involving the proximal part of facial artery. We present a case of a traumatic pseudoaneurysm involving the proximal part of facial artery. A 50-year-old man was referred to our department for a progressively growing submandibular mass. He was injured by a sharp object during a car crash 30 days ago. After 3 weeks, the patient noted the appearance of a subcutaneous mass in the left submandibular area. Physical examination revealed a freely movable, painful, and pulsatile swelling. Ultrasound and computerized tomography scan showed a nodular lesion in the left submandibular area in continuity with the facial artery. The diagnosis of pseudoaneurysm of facial artery was suspected. The patient was treated by surgery. The pseudoaneurysm was resected with ligation of the proximal and distal ends of the facial artery.

Pseudoaneurysm in internal maxillary artery after gunshot wound: Critical review and case report

INTRODUCTION

Pseudoaneurysm is a vascular injury typically caused by rupture of arteries with extravasation of blood. The involvement of this entity in facial arteries after firearm aggression is extremely rare, and they need treatment as early as possible, thus avoiding irreversible damage to patients.

STUDY DESIGN

A 40-year-old male victim of gunshot attack with an entrance orifice in the right posterior cervical region with ascending trajectory, lodging in the ipsilateral zygomatic-orbitary complex, which was submitted to removal of the bone fragments and the bullet. In the intraoperative period, the patient developed profuse hemorrhage and, after complementary examinations, he was diagnosed with pseudoaneurysm of the internal maxillary artery, which was treated by selective endovascular embolization.

RESULTS

The patient was hemodynamically stable, with no complaints and was discharged after 48 hours, without postoperative bleeding recurrences. He had no more complications after 8 months of follow-up.

CONCLUSIONS

The main forms of treatment and diagnosis of vascular lesions are reviewed, and embolization is demonstrated as a technically safe procedure with few complications. Key words:Gunshot wound, pseudoaneurysm, maxillary artery, therapeutic embolization.

Traumatic Pseudoaneurysm of the Internal Maxillary Artery: A Rare Life-Threatening Hemorrhage as a Complication of Maxillofacial Fractures

Pseudoaneurysm of the internal maxillary artery due to a traumatic event is a rare condition. Pseudoaneurysms are usually directly produced by arteries break with extravasation of blood. The compressed perivascular tissue forms the wall of aneurysmal sac. Then, this sac gradually expands and can be damaged. It is rare to see pseudoaneurysms of IMA. They are usually associated with fracture of the neck of the mandible. To the best of our knowledge the pseudoaneurysm of the internal maxillary artery related to maxillofacial trauma is an event extremely rare in the literature and if not quickly managed can lead to the patient's death. This case underlines how the close cooperation between surgeons and radiologists results in a quick diagnosis and management of such pathological events.

Management of Late Post-traumatic Facial Artery Pseudoaneurysmal Cyst: Review of Literature

Pseudoaneurysms of the branches of the external carotid artery as a result of trauma are rare in oral and maxillofacial surgery practice. The most affected branches are the superficial temporal artery, internal maxillary artery and distal part of facial artery, usually where they pass over the bone. Very few cases of facial artery pseudoaneurysms of proximal parts (from external carotid artery up to the lower border of the mandible) are reported in the literature. We present a review of literature for management of late post-traumatic pseudoaneurysmal cyst and a case report involving proximal part of facial artery in the submandibular region following open reduction and rigid fixation of the condylar fracture in a 25-year-old male. To our knowledge this is the fourth reported case of proximal facial artery pseudoaneurysm.

Pseudoaneurysm of internal maxillary artery--an untold complication following distraction osteogenesis--a case report

Pseudoaneurysm of the internal maxillary artery is very rare and only a handful of cases have been reported in the literature thus far and none after placement of a prosthetic condyle and a distraction device. This case report highlights the need for early diagnosis, appropriate steps in management, and a multidisciplinary approach in a tertiary care center in treating this life-threatening condition and proper treatment planning to prevent this condition.

Endovascular treatment of intractable bleeding from a traumatic pseudoaneurysm of the internal maxillary artery

Traumatic pseudoaneurysms of the internal maxillary artery (IMA) are rare and difficult to treat. A 58-year-old man with a traumatic pseudoaneurysm of the IMA presented with intractable nasal and oral hemorrhage during dual antiplatelet therapy. Transcatheter artery embolization with N-butyl cyanoacrylate (NBCA) completely occluded the pseudoaneurysm. Transcatheter artery embolization with NBCA is a feasible and effective treatment because of its shorter treatment time and lower incidence of recurrence.

Management of pseudoaneurysm of internal maxillary artery resulting from trauma

Pseudoaneurysm of internal maxillary artery following trauma is a rare clinical entity. A rapidly growing swelling in the facial region following fracture of the mandibular subcondylar region is an indication of a developing aneurysm. A case of pseudoaneurysm of the internal maxillary artery following condylar fracture of mandible is reported. The case was treated successfully by surgery.

Traumatic pseudoaneurysm of the superficial temporal artery

Aneurysms of the superficial temporal artery are relatively rare vascular complications following trauma. Two cases of pseudoaneurysm of the anterior branch of the superficial temporal artery, subjected to blunt maxillofacial trauma are presented here. The first case was treated by surgical resection and the second was cured by application of continuous pressure. The review of the English literature has also been included. An awareness of these vascular injuries, despite their infrequency, is necessary to facilitate early diagnosis, proper investigation and prompt treatment.

Iatrogenic pseudoaneurysm: a rare complication of sinonasal surgery

OBJECTIVE

We report 2 patients with iatrogenic pseudoaneurysms, which developed following sinus surgery.

METHOD

Case reports and a review of literature of the management of iatrogenic pseudoaneurysm.

RESULTS

For one patient who presented with massive epistaxis, the only lifesaving option available was to perform an urgent angiogram followed by selective embolization of the feeding vessel. In the second patient who presented with persistent nasal obstruction and discharge and no epistaxis, a traumatic aneurysm of the internal carotid artery was demonstrated on magnetic resonance imaging scan that was later confirmed by angiography; he, however, declined further treatment.

CONCLUSION

Iatrogenic pseudoaneurysms that develop following a vascular injury, though rare, can cause life-threatening epistaxis or a thromboembolism. In this report, we describe 2 different manifestations of iatrogenic vascular malformations following sinus surgery. The role of angiography and subsequent endovascular therapy in the management of these lesions is emphasized.

Massive repeated nose bleeding after bimaxillary osteotomy

In LeFort I surgery, the separation of the pterygomaxillary junction is done by osteotomy. Although the osteotome is positioned too close to the maxillary artery and its branches during pterygomaxillary separation, postoperative complications from vascular injuries are uncommon. We describe an unusual occurrence of a maxillary artery pseudoaneurysm after LeFort I and bilateral sagittal split osteotomies for maxillary advancement and mandibular setback as well as (anterior sliding) genioplasty. In a patient with class III occlusion and midface retrusion, the significant bleeding began 10 days postoperatively, which was controlled by anterior and posterior nasal packing. The bleeding recurred 28 days after surgery; thus, vascular anatomy in the pterygomaxillary area is reviewed, pseudoaneurysm was diagnosed on selective carotid angiography and successfully treated by embolization; and 2-year follow up was uneventful.

Role of CT and endovascular embolization in managing pseudoaneurysms of the internal maxillary artery

BACKGROUND

The purpose of this study was to evaluate the role of computed tomography (CT) and endovascular embolization in managing 10 patients with 11 internal maxillary arterial pseudoaneurysms (IMPAs) with acute oronasal hemorrhage.

METHODS

A series of 10 patients with 11 IMPAs presenting with profuse oronasal hemorrhage, all treated with endovascular embolization, were reviewed. There were 9 males and 1 female ranging in age from 10 to 56 years (mean, 38 years). The predisposing factors of IMPA were trauma (n = 6) or head and neck carcinomas (HNCs) after surgical treatment and/ or postradiation therapy (n = 5). Before embolization, all patients had CT of maxillofacial regions to evaluate the extension of trauma or to evaluate the treatment outcome for HNCs. Endovascular embolization was employed-to occlude the IMPAs by delivering the embolic agents of liquid adhesives (n = 9) or microcoils (n = 2) to the IMPAs.

RESULTS

On the lesion side, CT revealed maxillofacial fractures in all 5 trauma patients and recurrent or residual tumors in 3 patients with HNCs. In the other 2 patients with HNCs, CT showed no significant finding and contributed little to the catheter angiography in detecting the IMPAs. Endovascular treatment was technically successful in all 11 IMPAs, ceasing hemorrhage immediately after embolization. No recurrence of bleeding was observed. No patient developed neurologic deficit, skin, or mucosal necrosis at the maxillofacial region. Clinical follow-up was 2-36 months (mean, 14 months). Two patients with advanced carcinoma died during follow-up because of disease progression.

CONCLUSION

CT is a useful tool for guiding catheter angiography to localize the majority of IMPAs. Endovascular embolization can succeed in managing IMPAs, and should be performed as soon as the IMPA is depicted.

Unusual late vascular complications of sagittal split osteotomy of the mandibular ramus

Intraoperative or early postoperative vascular complications are not uncommon problems in sagittal split osteotomies of the mandibular ramus; however, reports of late complications are considerably rarer. Here, we present two patients who sustained late vascular complications after the sagittal split osteotomy. The first patient had a delayed bleeding, which presented itself as a rapidly expanding swelling of the left cheek from the left external carotid artery 18 days postoperatively. During exploration, a 2 mm laceration of the external carotid artery located just proximal to the bifurcation of the internal maxillary artery and the superficial temporal artery was successfully repaired. The prominent bony spike of the cut end of medial cortex of the set-back mandibular ramus was found against the arterial wall and could possibly have caused the progressive necrosis of the wall with subsequent spontaneous rupture. The second patient suffered from a mild noise in the right ear 2 weeks after the initial surgery; however, a pre-auricular arteriovenous fistula between the right external carotid artery and the external jugular vein was discovered 1 year postoperatively. The diagnosis was confirmed by angiography, and the lesion was treated successfully by therapeutic embolization at that time. To avoid vascular injury, sufficient protection of the soft tissue during exposure of the mandibular ramus is mandatory. In addition, the direction of the cut of medial cortex is suggested to avoid the cranialward inclination that creates a sharp, bony end against the artery. Awareness of the possible late vascular complications to facilitate early detection and management is also important.

Delayed presentation of pseudoaneurysm after Le Fort I osteotomy

Although the osteotome is positioned in close vicinity to the maxillary artery and its branches during ptergomaxillary separation in a Le Fort I osteotomy, postoperative complications from vascular injuries are rare. The following report describes an unusual occurrence of a maxillary artery pseudoaneurysm following a Le Fort I and bilateral sagittal-split osteotomies for correction of mandibular and maxillary asymmetries in a patient with Goldenhar syndrome. This was recognized 8 months after the procedure when the patient developed acute facial swelling and required an emergent angiogram for uncontrolled bleeding. Vascular anatomy in the ptergomaxillary area is reviewed. A level of suspicion of occult vascular injuries in patients with sudden onset of unilateral facial swelling after orthognathic surgery, even months after the procedure, is recommended.

Embolization for the treatment of pseudoaneurysm and transection of facial vessels

Transection of the facial and the internal maxillary arteries while routine operations were performed was the cause of uncontrolled bleeding and a pseudoaneurysm. We present a study of the mechanisms that create and the means that control hemorrhage and pseudoaneurysms in the maxillofacial region.