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.