Traumatic cavernous internal carotid artery pseudoaneurysm presenting with massive epistaxis-a morbid clinical entity


  • Santosh Kumar Swain Department of Otorhinolaryngology, IMS and SUM hospital, Siksha “O” Anusandhan University, Kalinganagar, Bhubaneswar, Odisha, India



Internal carotid artery, Pseudoaneurysm, Carotid angiography, Endovascular coiling


Epistaxis is commonly encountered by clinicians in emergency department. However, severe and recurrent epistaxis is very uncommon especially that arise from the cavernous internal carotid artery (ICA) pseudoaneurysm. Traumatic cavernous internal carotid pseudoaneurysm is a rare cause of the epistaxis but is a fatal and life-threatening clinical condition if left untreated. Massive epistaxis following head injury should alert the clinician to rule out traumatic cavernous ICA pseudoaneurysm. Traumatic pseudoaneurysm of the cavernous part of the ICA is a challenging clinical entity both in diagnosis and treatment. This clinical diagnosis may be suspected in case of patient with history of head injury, massive recurrent epistaxis and delayed onset of blindness. Massive epistaxis after head trauma should alert the clinician for possible cavernous ICA pseudoaneurysm. Carotid angiography confirms the site of pseudoaneurysm. The treatment options are endovascular stent and coil embolization, arterial balloon occlusion and surgical trapping. Timely diagnosis and treatment of this condition give a favorable outcome. In this review article, we discuss the epidemiology, etiopathology, clinical presentations, investigations and current treatment of the traumatic cavernous ICA pseudoaneurysm.


Guha A, Schalek P, Chovanec M. Syndromes that predispose to epistaxis. European Archives of Oto-Rhino-Laryngol. 2019;276(4):939-44.

Kim JY, Farkas J, Putman CM, Varvares M. Paraclinoid internal carotid artery aneurysm presenting as massive epistaxis. Ann Otol Rhinol Laryngol. 2000;109:782-6.

Monux A, Tomas M, Kaiser C, Gavilan J. Conservative management of epistaxis. J Laryngol Otol. 1990;104:868-70.

Swain SK, Sahu MC, Baisakh MR. Nasal myiasis in clinical practice. Apollo Med. 2018;15(3):128.

Moreau S, De Rugy MG, Babin E, Courtheoux P, Valdazo A. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope. 1998;108:887-8.

Manuel AM, Kalimuthu S, Pathmanathan SS, Narayanan P, Abidin ZZ, Azmi K et al. A. Challenges in the management of massive intraorbital and hemifacial arteriovenous malformation as causing life-threatening epistaxis. Asian j sur. 2017;40(2):158-62.

Bars HW, Blackwood W, Meadows SP. Intracavernous carotid aneurysms. A clinical-pathological report. Brain. 1971;94:607-22.

Higashida RT, Halbach VV, Dowd C, Barnwell SL, Dormandy B, Bell J et al. Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases. J Neurosurg. 1990;72:857-63.

Agarwal V, Phadke RV, Singh V. Posttraumatic internal carotid artery pseudoaneurysm: endovascular management by stent–graft placement. Indian J Neurotrauma. 2016;13(02):116-9.

Talamonti G, Aliberti GD and Collice M. Management of traumatic intracranial aneurysms. In: Schmidek and Sweets operative neurosurgical techniques: Indications, methods and results. 6th ed. Philadelphia, USA: Elsevier. 2012;1611-8.

Krings T, Mandell DM, Kiehl TR Geibprasert S, Geibprasert S, Geibprasert S et al. Intracranial aneurysms: From vessel wall pathology to therapeutic approach. Nat Rev Neurol. 2011;7:547-59.

Renn WH, Rhoton AL. Microsurgical anatomy of the sellar region. J Neurosurg. 1975;43:288-98.

Ghorayeb BY, Kopaniky DR, Yeakley JW. Massive posterior epistaxis: A manifestationof internal carotid injury at the skull base. Arch Otolaryngol Head Neck Surg. 1988;114:1033-37.

Radkowski D, McGill TJ, Healy GB, Jones DT. Penetrating trauma of the oropharynx in children. Laryngoscope. 1993;103:991-4.

Struffert T, Buhk JH, Buchfelder M, Rohde V, Doerfler A, Knauth M. Coil migration after endovascular coil occlusion of internal carotid artery pseudoaneurysms within the sphenoid sinus. min-Minimally Invasive Neurosur. 2009;52(02):89-92.

Cohen JE, Ben-Hur T, Gomori JM, Umansky F, Lylyk P, Rajz G. Stent-assisted arterial reconstruction of traumatic extracranial carotid dissections. Neurol Res. 2005;27(1):73-8.

Brasiliense LB, Dumont TM. Alarming internal carotid artery aneurysm eroding the sphenoid sinus. World neurosurg. 2017;108:985-e13.

Han MH, Sung MW, Chang KH, Min YG, Min YG. Traumatic pseudoaneurysm of the intracavernous ICA presenting with massive epistaxis: imaging diagnosis and endovascular treatment. Laryngoscope. 1994;104:370-7.

Goleas J, Mikhael MA, Paige ML, Wolff AP. Intracavernous carotid artery aneurysm presenting as recurrent epistaxis. Ann Otol Rhinol Laryngol. 1991;100:577-9.

Linskey ME, Sekhar LN, Hirsch W, Jr., Yonas H, Horton JA. Aneurysms of the intracavernous carotid artery: clinical presentation, radiographic features, and pathogenesis. Neurosur. 1990;26:71-9.

Al-Jehani HM, Alwadaani HA, Almolani FM. Traumatic intracranial internal carotid artery pseudoaneurysm presenting as epistaxis treated by endovascular coiling. Neurosci. 2016;21(1):60.

Swain SK, Sahu MC. An unusual complication of nasal foreign body in a pediatric patient: A case report. Pediatria Polska. 2017;92(1):111-3.

Swain SK, Sahu MC. An unusual giant isolated mucosal malignant melanoma of nasal cavity-A case report. Egyptian J Ear, Nose, Throat and Allied Sci. 2017;18:151-3.

Pandey P. Parent vessel occlusion and revascularization: a dying art? Neurol India. 2018;66:657-60.

Ambekar S, Madhugiri V, Sharma M, Cuellar H, Nanda A: Evolution of management strategies for cavernous carotid aneurysms: a review. World Neurosurg. 2014;82:1077-85.

Sekhar LN, Cheng C-Y, Da Silva HB, Qazi Z: What is the current role of bypass surgery in the management of cerebral aneurysms? Neurol India. 2018;66:661-3.

Mendez JC, Gonzalez-Llanos F. Endovascular treatment of a vertebral artery pseudoaneurysm following posterior C1-C2 transarticular screw fixation. Cardiovasc Intervent Radiol. 2005;28:107-9.

Cothren C, Moore E, Ray C Jr. Carotid artery stents for blunt cerebrovascular injury. Perspect Vasc Surg Endovasc Ther. 2006;18:73.

Mathis JM, Barr JD, Jungreis CA, Yonas H, Yonas H, Vincent D et al. Temporary balloon test occlusion of the internal carotid artery: experience in 500 cases. Am J Neuroradiol. 1995;16:749-54.

De Vries EJ, Sekhar LN, Horton JA, Eibling DE, Janecka IP, Schramm VL Jr et al. A new method to predict safe resection of the internal carotid artery. Laryngoscope. 1990;100:85-8.

Swain SK, Mohapatra SS. A rare and fatal complication of ear syringing: Rupture of pseudoaneurysm at petrous internal carotid artery. Arch Trauma Res. 2018;7(4):166-8.

Lempert TE, Halbach VV, Higashida RT, et al. Endovascular treatment of pseudoaneurysms with electrolytically detachable coils. AJNR Am J Neuroradiol. 1998;19:907-11.

Swain SK, Mallik KC. Ear, nose, and throat foreign bodies in pediatric age. Med J Babylon. 2020;17(3):238.






Review Articles