CASE REPORT
Mulher, 43 anos, referindo dor no hemicrânio esquerdo há seis meses, com piora nos últimos dez dias. A tomografia computadorizada (TC) revelou lesão expansiva paramediana em rinofaringe esquerda e a biópsia revelou um carcinoma espinocelular de nasofaringe. Um mês depois, foi internada com epistaxe maciça causando hipovolemia. Após 24 horas, a paciente apresentou nova epistaxe, sendo decidido tratar cirurgicamente. A lesão tumoral foi dissecada e foi possível visualizar uma lesão na porção petrosa da artéria carótida interna (ACI) esquerda, que a angiografia de subtração digital (ASD) confirmou como pseudoaneurisma. Após nova epistaxe maciça no dia seguinte, optou-se pela ligadura da ACI esquerda, com ASD realizada posteriormente mostrando permeabilidade vascular cerebral esquerda pela ACI direita. A paciente permanece consciente e sem sangramentos, embora apresente déficit neurológico focal. Os pseudoaneurismas de ACI são raros, representando menos de 1% de todos os aneurismas intracranianos, mas estão associados a morbidade e mortalidade significativas. A ASD é o padrão-ouro para o diagnóstico de pseudoaneurismas intracranianos. O tratamento inclui cirurgia, tratamento endovascular ou terapia conservadora. Apesar de incomum, a epistaxe recorrente é um sinal de alerta para pseudoaneurisma de ACI em pacientes com neoplasia de rinofaringe e base de crânio.
A 43-year-old female patient reported a left hemicranial pain for six months, worsening in the last ten days. Computerized tomography (CT) revealed an expansive paramedian lesion in the left rhinopharynx, and biopsy revealed a nasopharyngeal squamous cell cancer. One month later, she was admitted with massive epistaxis causing hypovolemia. After 24 hours, the patient presented a new epistaxis, which was decided to manage surgically. The tumoral lesion was dissected and it was possible to visualize a lesion in the petrous portion of the left internal carotid artery (ICA), which the digital subtraction angiography (DSA) confirmed as a pseudoaneurysm. After a new life-threatening epistaxis in the following day, it was decided for a left ICA ligation, with DSA performed later showing left cerebral vascular permeability through the right ICA. The patient remains conscious and without new bleedings, although a focal neurological deficit. ICA pseudoaneurysms are clinically rare, accounting for less than 1% of all intracranial aneurysms, but are associated with significant morbidity and mortality. DSA is the gold standard for diagnosis of intracranial pseudoaneurysms. Treatment includes surgery, endovascular treatment or conservative therapy. Albeit uncommon, recurrent epistaxis is a red flag for ICA pseudoaneurysm in patients with rhinopharyngeal and skull base neoplasia.
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(1) Department of Neurosurgery, Faculty of Medicine, Federal University of Ceará, Sobral (CE), Brazil.
(2) Department of Neurosurgery, North Regional Hospital, Sobral (CE), Brazil.
(3) Department of Otolaringology, North Regional Hospital, Sobral (CE), Brazil.
Received Mar 2, 2022
Accepted Mar 23, 2022
