Introduction
Massive epistaxis caused by rupture of the internal carotid artery (ICA)
is a crisis. Failure of hemostasis or in controlling treatment
complications has led to an increased mortality rate by one-third
[1,2]. For decades, previous studies have reported treatment methods
such as high-flow bypass [1,3-5] and endovascular treatment
[1,2,6-11]. In addition, it has been reported that one of the causes
of ICA rupture was skull base osteonecrosis due to second course of
irradiation for nasopharyngeal carcinoma (NPC) [1,2,6,8-10] or skull
base tumor [7].
Although several studies have reported that endovascular treatment
should be considered first [1,2,6-11], complete revascularization
rather than endovascular treatment should be preferred in some
situations: the balloon occlusion test (BOT) is not reliable due to
coma, and cannot be tolerated by some patients [1,2,6,7]. Meanwhile,
most of the reported cases were cases of recurrent malignant tumors
[1,2,6,8-10].
Herein, we describe a case of ICA rupture requiring radical
revisualization and skull base reconstruction. In this case, neither a
ruptured site nor pseudoaneurysm could be identified. Moreover, second
course of irradiation-induced osteonecrosis was due to the primary
disease: pituitary adenoma. The purpose of this report is to present how
we chose procedures for this atypical condition, in which the
prerequisites for endovascular treatment could not be identified and
long-term prognosis could be improved after definitive treatment was
achieved.