Standing Waves on Computed Tomography Angiography in Multiple Vessels in a Young Trauma Patient.

ABSTRACT: Standing waves are a phenomenon of uncertain etiology seen on imaging. We present the first case demonstrating standing waves on computed tomography angiography in multiple vessels in a single patient with imaging evidence of resolution in some of the vessels. Our case further supports the literature that standing waves are a physiologic phenomenon, likely because of flow mechanics, rather than modality.

Visual and semiquantitative assessment of cranial artery inflammation with FDG-PET/CT in giant cell arteritis.

BACKGROUND AND AIM: Assessing cranial artery inflammation plays an important role in the diagnosis of cranial giant cell arteritis (C-GCA). However, current diagnostic tests are limited. The use of fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT imaging is an established tool for assessing large vessel inflammation but is currently not used for assessment of the cranial arteries. This study aimed to evaluate the accuracy of FDG-PET/CT in the diagnosis of biopsy proven C-GCA and its relation to clinical presentation. METHODS: This retrospective case control study included temporal artery biopsy (TAB) positive C-GCA patients and age- and sex-matched controls. FDG-PET/CT scans were performed according to EANM/EARL guidelines, visually assessed by an experienced nuclear medicine physician, and semiquantitatively assessed using the maximum standardised uptake value (SUVmax). The visual and semiquantitative assessments were performed on the temporal arteries, maxillary arteries, vertebral arteries, and occipital arteries. Clinical signs and symptoms were scored for comparison. RESULTS: A total of 24 C-GCA patients and 24 controls were included in the study. Visual analysis revealed an 83% sensitivity and a 75% specificity. Receiver operating characteristic (ROC) analysis of the semiquantitative assessment revealed a 79% sensitivity and a 92% specificity when measuring SUVmax in the cranial arteries. Visual and semiquantitative assessments showed moderate agreement (Fleiss kappa 0.55). There was a positive correlation between the number of cranial symptoms and the SUVmax in the vertebral artery. CONCLUSION: FDG-PET/CT can reliably diagnose C-GCA by assessing cranial artery inflammation using SUVmax. Extending the use of FDG-PET/CT to include assessment of the cranial arteries may improve its diagnostic value in GCA and provide a suitable alternative to TAB. Moderate agreement between visual and semiquantitative assessment methods suggest diagnostic accuracy may be improved by further standardisation.

Severe facial necrosis in a type 1 diabetic patient secondary to mucormycosis masquerading as an internal maxillary artery occlusion: a case report.

BACKGROUND: Mucormycosis is a group of rare but life threatening angioinvasive infections caused by fungi of the order Mucorales that often occurs in immunocompromised patients and individuals with poorly controlled diabetes. Rhinocerebral mucormycosis can mimic sinusitis but can rapidly progress to deeper disease and cause facial necrosis. Facial vascular thrombosis is a rare complication of mucormycosis and can confound diagnosis of the disease. CASE PRESENTATION: We report the case of a 25-year-old female with poorly controlled type 1 diabetes mellitus who initially presented with symptoms of sinusitis but rapidly progressed with signs of left-sided facial necrosis due to occlusion of the left internal maxillary artery. Early surgical debridement did not yield a microbiological diagnosis. Deeper surgical debridements ultimately revealed angioinvasive fungal disease consistent with mucormycosis. The patient recovered after repeated surgical intervention and aggressive parenteral antifungal therapy. CONCLUSION: This case illustrates an atypical complication of mucormycosis, and emphasizes that a high index of suspicion in vulnerable patient populations aids in the diagnosis of this life-threatening infection.

The History and Evolution of Internal Maxillary Artery Bypass.

Internal maxillary artery (IMA) bypass has gained momentum in the last 5 years for the treatment of complex cerebrovascular disorders and skull base tumors. However, some issues regarding this treatment modality have been proposed. As one of the most experienced neurosurgical teams to perform internal maxillary artery bypass in the world (>100 clinical cases), we reviewed the literature in aspects of basic anatomy of maxillary artery with its variations to the lateral pterygoid muscle, initial anastomosis modalities, and subsequent exposure techniques in cadaver studies, preoperative arterial evaluation methods, optimal interposed graft selections, and surgical outcome in the management of complex aneurysms, skull base tumors, and steno-occlusive disorders.

A case of epistaxis.

The authors report a case of epistaxis in a 74-year-old male patient. His recent medical history documented recurrent nasal bleeding and a Le Fort 1 osteosynthesis 3 weeks before admission to our unit. A CT scan revealed a left descending palatine artery pseudoaneurysm in the left maxillary sinus that was successfully embolized. Pseudoaneurysms of the internal maxillary artery and its branches are rare life-threatening complications. This diagnosis should be considered when confronted to recurrent head and neck bleeding, especially in a context of recent maxillo-facial trauma or surgery. Embolization should rapidly be implemented.

Life-threatening hemorrhage after zygomatic bone surgery. About 2 posttraumatic cases.

INTRODUCTION: Management of zygomatic bone fractures is still debated. Method and delay for intervention has to be chosen considering respective issues of operative or conservative treatments, especially hemorrhagic complications. The maxillofacial surgeon must be able to determine life-threatening situations and to react appropriately. CASES REPORT: We report 2 cases of external carotid branches pseudoaneurysm leading to massive hemorrhage after early or delayed zygomatic fracture surgery. The first patient underwent open reduction of fracture by intraoral approach. An active bleeding occurred in the immediate postoperative time. In the second case, a zygomatic osteotomy was performed 1 year after fracture. Bleeding occurred 2 weeks after surgery. In both cases, angiography demonstrated a pseudoaneurysm developed from the external carotid branches. Embolisation led to rapid bleeding control. DISCUSSION: Severe hemorrhage resulting from maxillofacial trauma may be life-threatening. Once the "damage control" principles applied, selective embolisation of external carotid branches is an efficient alternative to surgery for the control of bleeding resulting from ruptured pseudoaneurysm.

Transarterial N-Butyl-2-cyanoacrylate Embolization of an Intraosseous Dural Arteriovenous Fistula Associated With Acute Epidural Hematoma: Technical Case Report.

BACKGROUND AND IMPORTANCE: Intraosseous dural arteriovenous fistulae (DAVF) are rare, especially those with drainage into the diploic venous system. The clinical presentation depends on the location of the lesion. This is the first report of an intraosseous DAVF associated with acute epidural hematoma. CLINICAL PRESENTATION: A 25-year-old man presented with headache and nausea. Imaging of the brain revealed abnormal signals indicative of acute epidural hematoma in the right frontal convexity. Angiography demonstrated a DAVF in the region of the frontal bone. Right external carotid artery angiography showed that the DAVF was fed mainly by the right middle meningeal artery with drainage into diploic veins. Immediately after embolization of the middle meningeal and the distal internal maxillary artery with 17% N-butyl-2-cyanoacrylate, the shunt was completely occluded. The patient was discharged 4 days later without clinical complications. CONCLUSION: Intraosseous DAVF can be treated by surgical resection or endovascular embolization. Curative treatment requires careful inspection of the angiographic architecture and microsurgical anatomy.

Bypass of the maxillary artery to proximal middle cerebral artery.

OBJECTIVE: The objective of this work was to explore the feasibility of bypass between the maxillary artery (MA) and proximity of middle cerebral artery (MCA). METHODS: Ten fixed and perfused adult cadaver heads were dissected bilaterally, 20 sides in total. The superficial temporal artery and its 2 branches were dissected, and outer diameters were measured. The MA and its branch were exposed as well as deep temporal artery; outer diameter of MA was measured. The lengths between the external carotid artery, internal carotid artery, maxillary artery, and proximal middle cerebral artery were measured. Ten healthy adults as targets (20 sides), inner diameter and blood flow dynamic parameters of the common carotid artery, external carotid artery, internal carotid artery, maxillary artery, superficial temporal artery, and its 2 branches were done with ultrasound examination. RESULTS: The mean outer diameter of MA (2.60 ± 0.20 mm) was larger than that of the temporal artery trunk (1.70 ± 0.30 mm). The mean lengths of graft vessels between the internal carotid artery, external carotid artery, and the bifurcation section of MCA (171.00 ± 2.70 and 162.40 ± 2.60 mm) were longer than the mean lengths of graft vessels between MA and MCA bifurcation section (61.70 ± 1.50 mm). In adults, the mean blood flow of the second part of MA (62.70 ± 13.30 mL/min) was more than that of the 2 branches of the superficial temporal artery (15.90 ± 3.70 mL/min and 17.70 ± 4.10 ml/min). CONCLUSION: Bypass between the maxillary artery and proximity of middle cerebral artery is feasible. It is a kind of effective high flow bypass with which the graft vessel is shorter and straighter than the bypass between internal carotid artery or external carotid artery and proximity of middle cerebral artery.

Maxillary-fronto-temporal approach for removal of recurrent malignant infratemporal fossa tumors: Anatomical and clinical study.

PURPOSE: For recurrent malignant tumors occurring in the infratemporal fossa, it is difficult to select a proper surgical approach. We explore the efficiency of a new approach for removal of recurrent malignant tumors involving the infratemporal fossa based on the measurement on three-dimension CT, observation of six cadaveric specimens, and our surgical experience. MATERIALS AND METHODS: The distances between the surgical landmarks in the infratemporal fossa were measured using CT data to determine the safe distance. And anatomy observation was examined on 6 formalin-fixed cadaveric specimens. Data from seven patients with recurrent malignant infratemporal fossa tumors were retrospectively analyzed. RESULTS: The mean distance of the medial pterygoid plate from the zygoma was 52.12 mm. The maxillary artery can be found between the deep surface of the condyle and the sphenomandibular ligament, with mean distance of 8.25 ± 3.22 mm to the inferior border of the capsule of the temporomandibular joint. All tumors got gross resection using the maxillary-fronto-temporal approach with minor complication. CONCLUSIONS: The advantages of the new approach include adequate protection of facial nerve with extended operation field; the exposed temporal muscle could be used to fill the dead space. This technique is especially useful to remove recurrent malignant infratemporal tumors safely.

[Optimization of the surgical methods for the treatment of recurrent nasal bleeding (a pathologo-anatomical study)].

The objective of the present work was to study specific features of blood supply to the nasal cavity by staining mandibular and ethmoidal arteries to reveal their size and topographic features under conditions of a pathologo-anatomical department. The secondary objective was to modify the existing and develop new methods for the ligation of these vessels. This pathologo-anatomical study was based on 16 preparations examined with the use of up-to-date optical facilities. The results of investigations of the topographo-anatomical peculiarities of blood supply in the nasal cavity are supplemented by the evaluation of the potential of endoscopic rhinosurgery for the treatment of recurrent nasal hemorrhage. The methods for endoscopic ligation of mandibular and ethmoidal arteries have been developed and optimized.

Life-threatening haemorrhage after 750 Le Fort I osteotomies and 376 SARPE procedures.

This study assessed the incidence, presenting symptoms, diagnosis, and management of patients with life-threatening postoperative haemorrhage after total Le Fort I osteotomy and surgically assisted rapid palatal expansion (SARPE). The medical records of 750 consecutive Le Fort I osteotomies and 376 consecutive SARPEs, both of which involved pterygomaxillary separation with a curved osteotome and a mallet, were analysed prospectively. Two cases of life-threatening haemorrhage were observed in the Le Fort I osteotomy group, both initiated on postoperative day 7. Anterior and posterior nasal packing were successful in one patient; the other required two embolizations for bleeding control (incidence of life-threatening postoperative haemorrhage: 2/750; confidence interval: 0.03-0.96%). In the SARPE group, one brisk epistaxis on the first postoperative day was controlled with anterior and posterior nasal packing under general anaesthesia. This haemorrhage was not considered life threatening (incidence of life-threatening postoperative haemorrhage: 0/376; confidence interval: 0-0.98%). In no case could the source of bleeding be established during re-explorative surgery or during diagnostic arteriography. The authors conclude that life-threatening haemorrhage is an exceptional finding after Le Fort I osteotomy; the observed incidence was 2/750, and life-threatening haemorrhage was not observed after SARPE in this series, despite the use of identical pterygomaxillary separation.

Management of intractable spontaneous epistaxis.

BACKGROUND: Epistaxis is a common otolaryngology emergency and is often controlled with first-line interventions such as cautery, hemostatic agents, or anterior nasal packing. A subset of patients will continue to bleed and require more aggressive therapy. METHODS: Intractable spontaneous epistaxis was traditionally managed with posterior nasal packing and prolonged hospital admission. In an effort to reduce patient morbidity and shorten hospital stay, surgical and endovascular techniques have gained popularity. A literature review was conducted. RESULTS: Transnasal endoscopic sphenopalatine artery ligation and arterial embolization provide excellent control rates but the decision to choose one over the other can be challenging. The role of transnasal endoscopic anterior ethmoid artery ligation is unclear but may be considered in certain cases when bleeding localizes to the ethmoid region. CONCLUSION: This article will focus on the management of intractable spontaneous epistaxis and discuss the role of endoscopic arterial ligation and embolization as it pertains to this challenging clinical scenario.

Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective therapeutic option: technique, complications, and outcomes.

Epistaxis generally responds to conservative management, but a more invasive approach, such as superselective embolization, is sometimes justified. We report our experience with endovascular procedures in 19 patients from 2002 to 2011 for the treatment of refractory idiopatic posterior epistaxis. The sphenopalatine artery and distal internal maxillary arteries were embolized in all patients. Unilateral embolization was performed in 12 patients (63%), bilateral embolization in seven (37%). Additional embolization of the descending palatine artery was performed in eight patients (42%) and embolization of the facial artery and palatine arteries in four (21%). In one patient the distal ophthalmic artery was embolized with n-butyl cyanoacrylate. No minor or major complications occurred in relation to the embolization procedures. The average hospital stay was 11.1±8.6 days, including an average 5.2±3.4 days after embolization. Average follow-up after discharge was 21.3±25.7 months. Superselective endovascular embolization proved safe and effective in controlling idiopathic epistaxis, refractory to other maneuvers.

A novel use of a landmark to avoid injury of the anterior ethmoidal artery during endoscopic sinus surgery.

BACKGROUND: The aim of this study was to describe and correlate radiographically the anterior ethmoidal artery (AEA) to useful endoscopic surgical landmarks, such as the nasal beak (NB), nasal crest (NC), and axilla of the middle turbinate, because these are commonly encountered during endoscopic sinus surgery and skull base surgery. METHODS: A retrospective review and software analysis was performed by three independent observers. Measurements of distance and angulation from the AEA to the NC, NB, and axilla of the middle turbinate were performed. A total of 138 unique computed tomography (CT) scans performed at a university tertiary care center were evaluated. RESULTS: The average age of the patients whose scans were analyzed was 50.5 (range, 17-90 years) years of age. The gender distribution was 61 male and 89 female patients. After comparing the measurements to the three landmarks noted, it was determined that the NB had the most interpatient concordance and the least interobserver variability. The average distance between the NB and the AEA as it penetrates the lamina papyracea is 2.34 cm (variance, 0.07) at an angle of 45.21° from the Frankfurt horizontal line. CONCLUSION: The real advantage of this novel use of the NB as a landmark to identify the AEA is that it is easy to use, unobtrusive, and is not time-consuming. This relationship between the NB and the AEA is consistent across genders and ethnicities and is more valuable than others presented previously, which may be more variable.

Facial artery pseudoaneurysm without evidence of trauma.

False aneurysm or pseudoaneurysm is usually a result of blunt trauma causing laceration of part of the vessel wall and extravasation of blood into surrounding tissue, followed by tamponade and clot formation. The wall of the pseudoaneurysm consists of perivascular fibrous tissue. Extracranial carotid artery pseudoaneurysms are relatively rare because trauma to external carotid artery branches usually results in total transection rather then partial laceration of blood vessel. Most affected branches are the superficial temporal artery, internal maxillary artery and distal facial artery, usually where they pass over the bone (zygoma or mandible). The authors present the case of a 78-year-old male patient with facial artery pseudoaneurysm in its proximal part in the submandibular region with no known evidence of trauma. To the authors' knowledge this is the first case in the literature of facial artery pseudoaneurysm without traumatic origin and the third case of proximal facial artery pseudoaneurysm. Although formation of pseudoaneurysm in the region of face and neck is rare, the authors consider that inclusion of pseudoaneurysm in the differential diagnosis of a neck mass is important.

Pseudoaneurysm of the external carotid artery secondary to subcondylar fracture.

Arterial pseudoaneurysms are rare in oral and maxillofacial surgery, but when they occur, quick recognition and management is necessary to avoid devastating consequences. The authors report a case of a pseudoaneurysm of the external carotid artery that developed after open reduction and internal fixation of a mandibular condyle fracture.

Pressure injection demonstrates points of weakness in the posterior nasal arteries.

OBJECTIVE: To test the hypothesis that potential sites of weakness within normal nasal arteries, when stressed, contribute to the mechanism of epistaxis, we 'stress-tested' nasal arteries in unfixed cadaveric heads, using pressure injection of feeding arteries. MATERIALS AND METHODS: Indian ink with latex was injected into maxillary arteries under high pressure (620 mmHg). Stepwise dissection was carried out and areas showing ink leakage were examined. Control heads were injected at standard embalming pressures (375 mmHg). RESULTS: Ink leakage was found in all heads injected at higher pressure, and was restricted to the nasal mucosa. Histological examination of leakage points demonstrated vessel disruption consistent with dissecting aneurysm formation. DISCUSSION: Results showed that high pressure injection caused leakage from arteries in the posterior nose; the distribution of leakage points was consistent with many clinical investigations. The lesions produced were comparable with our best histopathological model of epistaxis, i.e. dissecting aneurysm formation. This suggests that pre-existing weaknesses in the arterial configuration may exist.

Role of CT angiography and embolisation in the management of life-threatening haemorrhage following microvascular head and neck reconstruction.

Post-operative haemorrhage in the head and neck cancer patient can have a catastrophic outcome either for the patient or the free flap if microvascular reconstruction has been performed. The life of the patient always takes priority over the flap; however the pedicle can be at risk when the patient is returned to theatre for arrest of the haemorrhage. CT angiography is a good non-invasive method of determining the source of bleeding and facilitating superselective embolisation, minimizing risk to the flap pedicle. We present a case which this treatment was successfully used with a good result and would recommend its use when similar situations occur.