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Carotid artery blowout syndrome (CBS) occurs when there is rupture of the carotid artery causing massive epistaxis and bleeding through the oral cavity caused by tumour invasion, surgery, radiotherapy, or infection. This article proposes a revascularisation strategy for internal carotid artery (ICA) embolisation and bypass grafting in the treatment of ICA CBS. Patients with grade 4 and grade 3 collateral circulation (American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology - ASITN/SIR), patients in good general condition (no emaciation, no anaemia, no hypoalbuminemia, etc.,) are embolised directly. Other grade 3 patients undergo ICA embolisation and single-branch superficial temporal artery (STA) and middle cerebral artery (MCA) bypass. Grade 2 patients undergo ICA embolisation and double-branch STA-MCA bypass. Grade 0-1 patients undergo high-flow bypass external carotid artery to MCA. The authors present results from a retrospective study of 69 patients admitted to Third Affiliated Hospital of Southern Medical University, Guangzhou, China, with ICA CBS between April 2018 and January 2020. Inclusion criteria: nasopharyngeal haemorrhage during treatment of nasopharyngeal carcinoma with surgery, chemotherapy or radiotherapy; ineffective haemorrhage control with nasal cavity tamponade; diagnosis confirmed by angiography. Sixty-two were of impending type (type II) and seven of the acute carotid blowout type (type III). Patients either had EBBA (internal carotid artery embolisation and bypass grafting) or embolisation/stenting. From January 2019, the authors used the ASITN/SIR score to evaluate collateral circulation, so most patients before 2019 had embolisation/stenting, and most patients after 2019 had EBBA. Forty-nine patients underwent EBBA. Of these, 10 cases had collateral circulation ASITN/SIR grade 4, 25 cases grade 3, 10 cases grade 2, and four cases grades 0-1; 41/49 (83.7%) survived; seven had cerebral ischaemic events in the first post-op week; 40 reported satisfactory quality of life (Modified Rankin Scale (mRS) 0-1) after three months. No deaths occurred within three months. Nonoperative death occurred in 8/49 (16.3%): five died of recurrent haemorrhage, one of cerebral haemorrhage, one asphyxia, and one of infection. The rate of mortality and disability was 9/49 (18.4%). Twenty patients underwent embolisation/stenting, 16 patients passing the balloon occlusion test were treated with direct ICA embolisation, and four that did not pass balloon occlusion received coils and stents; 16/20 (80%) survived; five had cerebral ischaemic events in the first post-op week; four reported an mRS score of 2 after three months. Nonoperative death occurred in 4/20 (20%) from recurrent hemorrhage and infection, of which three occurred within one-to-three months. The rate of mortality and disability was 8/20 (40%).

Comprehensive Treatment Strategy for Internal Carotid Artery Blowout Syndrome Caused by Nasopharyngeal Carcinoma.
Zhao Z, Huang L, Chen J, et al.
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Richard (Wei Chern) Gan

Royal Brisbane and Women's Hospital, Australia.

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