Abstract

Severe epistaxis following head injury occur from damage to the anterior ethmoidal or sphenopalatine arteries. However, the more massive, life-threatening posttraumatic epistaxis is that arising from ruptured aneurysm, arteriovenous fistula, or tear of the intracranial extradural portion of the internal carotid artery. The authors had opportunities to treat successfully 3 cases of massive delayed epistaxis from the aneurysm of this site following closed head injury. Case 1. A 23-year-old man was injured in a motorcycle accident on April 19, 1968 and taken to an emergency hospital, where the findings were semicomatose state, profuse bleeding from the left nostril and oral cavity, and laceration above the left eye associated with fracture of the left sphenoid. Since regaining consciousness he was blind in the left. Slight localized protrusion of the cavernous portion of the left internal carotid was shown by angiography, which was performed on the next day (Fig. 1). Three days later, he was transfered to Toyokogyo Hospital. On April 29, he had sudden severe epistaxis. The nasal bleeding recurred massively 6 times over 2 months, requiring the replacement of more than 8000 cc of blood. Sixty days after the trauma, carotid angiography demonstrated an large aneurysm arising from the left internal carotid (Fig. 2). The authors were consulted on this occasion. Intra- and extracranial trapping of the internal carotid artery associated with muscle embolization (Jaeger's operation) was performed (Fig. 3). Postoperative course was uneventful except occurrence of temporary diabetes insipidus. Case 2. This 59-year-old man was admitted to our clinic on November 7, 1970, Because of posttraumatic recurrent massive epistaxis. Thirty-seven days before admisstion, he was hitted by a car and lost consciousness. Profuse nasal bleeding occurred immediately after the accident. Despite skin lacereation above the right eye, visual acuity was not distrubed and no fracture line was found. Two weeks after the injury, he had sudden massive bleeding from the right nostril. The epistaxis recurred 5 times over 3 weeks. Carotid angiography revealed an aneurysm arising from the right internal carotid (Fig. 4). The internal carotid was gradually occluded at the cervical level without any neurological complication. Case 3. A 33-year-old man was referred to our department on October 7, 1974, complaining of recurrent profuse bleeding from the oral cavity. About 2 months prior to admission, he fell from the fourth floor on the street and became comatose. Several fracture lines of the frontal bones were found on skull film. Thirty-six days after the accident, sudden severe epistaxis occurred. Massive bleeding from the oral cavity repeated every 7 to 10 days. Visual acuity was lost within 10 weeks. III and VI cranial nerves palsy was found on the both sides. Carotid angiography demonstrated a small aneurysm of the left internal carotid (Fig. 5). Occlusion of the internal carotid at the cervical level stopped bleeding without further neurological deficit...