Emergency high-flow bypass for the management of ruptured postirradiated internal carotid artery pseudoaneurysms in nasopharyngeal carcinoma patients

Rupture of a postirradiated internal carotid artery (ICA) pseudoaneurysm in patients with nasopharyngeal carcinoma (NPC) is a rare yet life-threatening emergency. In contrast to pseudoaneurysms found in patients with other head and neck malignancies, those identified in NPC patients have a propensity to occur in the petrous segment of the ICA, which pose a serious challenge to clinical physicians. Over the past few decades, endovascular treatment with covered stents has widely been adopted as the treatment of choice for patients at risk of brain ischemia after occluding the parent vessel of the pseudoaneurysm. Although recent series have demonstrated that immediate hemostasis can be achieved in most of the patients undergoing covered stent placement, a high incidence of delayed complications has been reported, including delayed cerebral ischemia, in-stent thrombosis, and septic thromboembolism. We present two NPC patients with a postirradiated pseudoaneurysm involving the petrous segment of the internal carotid artery. As direct parent vessel occlusion was infeasible, we established an emergency high-flow extracranial-intracranial (EC-IC) bypass followed by endovascular parent vessel occlusion. Both of the patients were followed-up for more than 24 months without neurological deficit or rebleeding. We suggest that EC-IC bypass with parent vessel occlusion should be considered as a practical and durable treatment option for patients with postirradiated ICA pseudoaneurysms who cannot tolerate direct carotid occlusion.