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LETTER TO THE EDITOR
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Nasopharyngeal Bleeding with Orbital Perfusion from External Carotid Artery with No Flow from Internal Carotid Artery


1 Department of Neurology and Critical Care Medicine, Regions Hospital, Saint Paul, MN, United States
2 Neurointerventional, Radiology Department, Midwest Radiology, Saint Paul, MN, United States
3 Research Department, Colombian Clinical Research Group in Neurocritical Care, Bogota, Colombia

Date of Submission08-Mar-2022
Date of Decision28-Apr-2022
Date of Acceptance28-Apr-2022
Date of Web Publication19-Jul-2022

Correspondence Address:
Luis R Moscote-Salazar,
Latinamerican Council of Neurocritical Care (CLaNI), Bogota
Colombia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_191_22



How to cite this URL:
Janjua T, Torok C, Moscote-Salazar LR. Nasopharyngeal Bleeding with Orbital Perfusion from External Carotid Artery with No Flow from Internal Carotid Artery. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=351328



Dear sir,

Intracranial blood flow has some anatomical variation such is absence of posterior communicating artery on one side. Moyamoya disease (MMD) is classically defined by pruning of blood vessels after circle of Willis and further tapering. MMD can be unilateral and seen over 70% in female patients.[1] Bilateral MMD usually present with intraventricular hemorrhage (IVH) while unilateral with subarachnoid hemorrhage.[2] We present a complex neurocritical care patient with unilateral MMD and IVH. The complication of nasopharyngeal hemorrhage led to challenging neurocritical care course.

A 61-year-right-handed female patient with remote history of seizure disorder and pulmonary histoplasmosis presented with high grade IVH. She was intubated and transfer to neurocritical care unit. On arrival, an emergent external ventricular device (EVD) was inserted. Her CT-angiogram (CTA) of brain showed absence of flow in left internal carotid and posterior cerebral artery. There was robust collateral flow consistent with chronic unilateral MMD. A formal cerebral angiogram confirmed CTA findings of unilateral MMD. Left external artery (ECA) angiogram was done to review the collateral and confirm the presence of adequate superficial temporal artery for future bypass. EVD was gradually weaned and taken out after 10 days and she was extubated on the 14th day. At 48 hours post extubation, she began with bleeding in the oral cavity, not being able to identify the area of bleeding. She was emergently intubated for aspiration and bronchoscopy confirmed fresh blood in the right lower lobe without any active bleeding. The thought was oral trauma from prolonged initial intubation led to this hemorrhage. She was given red blood cell and open tracheostomy was performed next day. She was weaned off the ventilator and plan was to start acute inpatient rehab. Two days post-tracheostomy, patient developed projectile bright red epitaxies. Immediate nasal packing was done though no active bleeder was seen and tracheotomy site was stable. At this stage, a multidisciplinary phone conference was arranged between neurocritical care, vascular neurosurgery, neurointerventioanl radiology, and otolaryngology. Cerebral angiogram was reviewed. It confirmed that extensive dilated and enlarged ECA branches are source of bleeding. Further reviewed showed that left eye blood flow was via ECA rather ICA [Figure 1]. Endovascular intervention was out of question as it would high likely lead to lost blood flow to left eye and blindness. Another brief episode led to reduction of SBP, which was kept under 160 mmHg, to under 130 mmHg. After this change, she stopped having any bleeding. Plan was to get her through the rehabilitation and revisit neurovascular revascularization planning in the near future.
Figure 1: Combined image: (a) (Lateral view, left vertebral artery angiogram) Robust left perisplenial (white arrow) and posterior choroidal (black arrow) collateralization, as well as PCA to MCA leptomeningeal collateralization (red arrow), in the context of moyamoya pattern steno-occlusive disease with (d) (Frontal view, right ICA angiogram) complete occlusion of the left ICA supraclinoid segment with patency of the terminus (white arrow). The left anterior circulation is supplied across the ACOM from the right anterior circulation. (c) (Lateral view, left ECA angiogram, arterial phase) Florid collateral network (red arrow) most prominently involving ethmoidal and anterior deep temporal artery anastomoses that reconstitute the ophthalmic artery supply (black arrow), as well as contributes to transdural collateralization of a portion of the left ACA territory parenchyma (white arrow) (b) (Lateral view, left ECA angiogram, venous phase). (e and f) (Lateral view, right ECA angiogram) Normal configuration for comparison

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Church EW, Bell-Stephens TE, Bigder MG, Gummidipundi S, Han SS, Steinberg GK. Clinical course of unilateral moyamoya disease. Neurosurgery 2020;87:1262-8.  Back to cited text no. 1
    
2.
Yu Z, Zheng J, Guo R, Li H, You C, Ma L. Patterns of acute intracranial hemorrhage in adult patients with bilateral and unilateral moyamoya disease. Curr Neurovasc Res 2019;16:202-7.  Back to cited text no. 2
    


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