"Unstoppable" nosebleeds

Casuistry A 59-year-old male patient was transferred emergency with an unstoppable nosebleed. Two surgical attempts to stop the epistaxis by sclerotherapy of the sphenopalatine artery on both sides and by Bellocq tamponade were performed. In addition, a total of 8 erythrocyte concentrates were transfused. After transfer, the patient was immediately treated under intubation anesthesia (ITN). Intraoperatively, a circular, pulsatile mucosal lesion was seen at the base of the clivus. After probing, there was an impression of bony erosion at the junction of the posterior wall of the epipharynx and the clivus. The defect was covered with Tabotamp and the nasal cavity was tamponaded on both sides. Subsequent cranial CT and cranial MR angio in ITN revealed an extensive destructive process in the left nasopharyngeal roof with bony erosion of the adjacent skull base and formation of a 34 mm x 22 mm pseudoaneurysm of the left internal carotid artery. The aneurysm was coiled and no rebleeding occurred. Biopsy revealed granulating ulcerative inflammation. Under resistance antibiotic treatment with imipinem and cilastatin, the patient’s general condition improved rapidly and he could be transferred back to a rehabilitation hospital. The control CT and MRI examination 3 months later showed the previously known findings of the skull base without further progression.

Conclusion Pseudoaneurysm of the internal carotid artery is a rare but life-threatening cause of unstoppable nosebleeds. Pulsatile hemorrhage in the epipharyngeal roof with palpable bony defect of the skull base were the landmark findings for extended cross-sectional imaging in our case report.

Publication History

Article published online:
27 June 2023