Case report
A 67-year-old woman, who has been followed up for osteonecrosis of the sphenoid bone, right blindness, and hypopituitarism by our department in the last 3 years after multidisciplinary treatment of a pituitary tumor 20 years ago, presented with massive epistaxis. She had undergone two transsphenoidal microsurgeries and craniotomy for pituitary adenoma, as well as radiation therapy including cobalt brachytherapy and gamma knife. On the day before her presentation at our hospital, a brief loss of consciousness was observed due to a sudden massive epistaxis that fortunately spontaneously stopped. An otorhinolaryngologist, who had followed her up due to osteonecrosis, especially the bone around the C3 segment of the right ICA that disappeared after chronic infection for 3 years (Figure 1A, B), considered a possibility of right ICA rupture due to her episode of massive epistaxis. Therefore, he consulted with neurosurgeons to evaluate the source of epistaxis. While waiting for the neurosurgeons, a massive epistaxis suddenly occurred again with loss of consciousness. Accordingly, the otorhinolaryngologist urgently attempted to stop bleeding using total nasal packing with a balloon catheter and impregnated ointment gauze. However, epistaxis continued despite the procedure and fortunately stopped spontaneously within a few minutes (Figure 2A). Although the neurosurgeons performed conventional angiography, no noticeable findings were found in the right ICA (Figure 2B). Therefore, the neurosurgeons and otorhinolaryngologists first suggested that one of the peripheral branches of the right external carotid artery (ECA) was the source. Therefore, the neurosurgeon occluded the right sphenopalatine artery from which contrast medium appeared to leak slightly. The patient was admitted to the neurosurgical department with a generous cooperation of the otorhinolaryngologist performing blood transfusion and strict follow-up, in addition to suggesting ICA rupture.
After admission, massive epistaxis suddenly occurred again despite right sphenopalatine artery occlusion. Therefore, a high-flow bypass between the second segment of the right middle cerebral artery (MCA) and the right cervical ECA was urgently performed. This procedure comprised using radial artery (RA) graft, surgical trapping of the right ICA, and skull base reconstruction with a pedicle mucosal flap harvested from the left nasal floor accompanied by removal of necrotic tissue. First, a RA graft was sutured to the second segment of the right MCA end-to-side by interrupted suture and the right cervical ECA end-to-side by continuous suture. The ophthalmic segment of the right ICA was ligated using a clip, and the cervical segment was ligated. Thereafter, the otorhinolaryngologist endoscopically removed necrotic tissues on the sphenoidal bone without any damage to the dura mater and then covered the skull base and sphenoid sinus with a vascular pedicled nasomucosal flap harvested from the left nasal floor.
No postoperative epistaxis was observed. Although small watershed infarcts of the right hemisphere were observed, left paresis was transient after surgery. The patient was discharged one month after surgery without any residual disability. Revascularization was successful, and there was no evidence of decreased blood flow on single-photon emission computed tomography (Figure 3A, B). Additionally, chronic infection of the sphenoid bone improved (Figure 1C, D). She has been uneventful for 15 months after surgery.