Case Report

Transarterial embolization in the management of

Life-threatening hemorrhage after maxillofacial trauma: a case report and review of literature

Abstract

There are many reasons for hypotension in trauma patients. Life-threatening hemorrhage associated with maxillofacial trauma is considered rare. Here, we present a 25-year-old patient with maxillofacial trauma compli- cated by life-threatening hemorrhage after a traffic accident. At the emergency department, massive epistaxis was noted. Nasal packing and blood transfusion were performed, but vital signs of the patient were still un- stable. Cerebral angiography revealed contrast extravasa- tion from the left superficial temporal and internal maxillary arteries of the left external carotid artery. After transarterial embolization was performed, the hemorrhage immediately stopped. When common treatment such as nasal packing, correction of coagulopathy, reduction of fractures, and arterial ligation fails to control the hemorrhage, transarterial embolization can offer a safe alterative to surgical exploration.

Traffic accidents are an important cause of maxillofacial trauma because drivers have little facial protection. The incidence of maxillofacial trauma is 10% in most trauma centers [1]. Maxillofacial trauma is not always life- threatening, but the potential problems of airway compro- mise and severe hemorrhage can occur. Occasionally, emergent open reduction and internal fixation is necessary to control the life-threatening hemorrhage. Ligation of the external carotid artery may be necessary when these measures do not control the bleeding. These procedures have technique difficulties because of swelling of the neck and face, which are risks related to airway compromise and instability of the cervical spine. Transarterial embolization (TAE) is an alternative to surgical exploration. Here, we present a 25-year-old patient with life-threatening hemor- rhage after maxillofacial trauma caused by a traffic accident. Life-threatening hemorrhage was finally con- trolled by TAE.

A 25-year-old man sustained maxillofacial fracture after an automobile crash. He was sent to a local hospital

for first management and then transferred to our hospital because of exsanguinating nasal bleeding. Upon arrival, he was in semicoma (Glasgow coma scale equal E1M5V1). In addition, blood pressure, heart rate, and body temperature were 118/48 mm Hg, 133 beat/min, and 34.9?C, respectively. Because of risk of suffocation, endotracheal intubation was performed immediately and was followed by central venous catheter cannulation for fluid resuscitation. Unfortunately, his condition was still unstabilized after emergent blood transfusion and nasal packing. brain computed tomography revealed a focal epidural hematoma over the left anterior temporal fossa (Fig. 1) and multiple fractures, including bilateral zygomatic arches, maxilla, lateral orbital walls, nasal and ethmoid sinuses, as well as the central skull base (Fig. 2). Because persistent epistaxis was noted, balloon catheter was inserted through the nares and into the pharynx. The balloon was inflated by an ear, nose, and throat specialist to compress the nasopharynx. However, profuse epistaxis and hypotension (45/30 mm Hg) were still noted. The patient was then transferred to the neurosurgical intensive care unit. Cerebral angiography was arranged, and it revealed contrast extravasation from the left superficial temporal and internal maxillary arteries of the left external carotid artery (Fig. 3). After embolization of the bleeder with gelfoam pieces, the contrast extravasation ceased immediately. Postemboliza- tion angiography of the right internal and external Carotid arteries shows no evidence of active bleeding. The epistaxis subsided, and blood pressure stabilized after fluid resuscitation.

Trauma is one of the major causes of mortality and morbidity in the western world, especially among young adults. Injuries to the facial soft tissue and underlying bony skeleton constitute a high percentage of traumatic injuries in many emergency departments. Some medical literature support the content that maxillofacial trauma can rarely be life-threatening or lead to life-threatening problems [2]. The most serious life-threatening complica- tion is airway compromise [3]. Other causes of life- threatening complications after maxillofacial trauma are Massive bleeding or undiagnosed [3]. Avery et al [4] reviewed 567 patients with Facial fractures and only found 1.4% had severe hemorrhagic shock from their injuries.

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516.e4 Case Report

Fig. 1 Computed tomography of brain revealed a focal epidural hematoma over the left anterior temporal fossa.

Fig. 3 Angiography of left external carotid artery revealed contrast extravasation from the left superficial temporal and internal maxillary arteries of the left external carotid artery.

Buchanan and Holtman [5] reported on 108 patients for treatment of midface fractures and found 11% had significant bleeding.

Airway, breathing, and circulation should be addressed and managed in primary survey of trauma patients. However, airway protection is the most important in all

Fig. 2 Coronal facial computed tomography revealed bilateral zygomatic arches, maxilla, lateral orbital walls, nasal and ethmoid sinuses, as well as the central skull base.

trauma patients, especially in maxillofacial trauma patients, because mental obtundation from traumatic brain injury, soft tissue swelling, bleeding into oral cavity, and bilateral mandibular fracture all can cause the soft tissue of the low face and the tongue to fall backward and compromise the airway [6].

The origin of the bleeding in maxillofacial trauma is mainly from the external carotid artery, internal maxillary artery, and its intraosseous branch [7]. Duggan and Brylsky [8] reported that the origin of significant epistaxis is from either the ethmoid branches of the ophthalmic artery or the pharyngeal branches of the maxillary artery. In addition, the vidian artery and the capsular branch of Internal carotid artery may play a major role in the origin of bleeding [9]. The internal maxillary artery or its branches cause approximately 70% of patients uncon- trolled epistaxis [10]. The most significant threat for continued hemorrhage is the disruption of the maxillary artery and its branches [4].

Ardekian et al [7] reported various methods for treatment of bleeding from the maxillofacial region, including nasal packing, reduction of fracture, arterial ligation, angiography, and selective embolization. Nasal packing with gauze, Foley catheter, or triple-lumen balloon catheter is applied [11]. Temporary reduction of the fractures may stop bleeding from the intraosseous branches close to the fracture lines [7]. However, ligation of the external carotid artery is rarely effectively in managing life-threatening hemorrhage because of the rich collateral flow from the opposite side [4]. Angiography can detect the bleeding

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point with potential embolization [4]. Therefore, TAE with fibered microcoils and gelfoam pledgets of carotid artery and its branches can provide a valuable alternative to control hemorrhage [4].

According to the guideline for maxillofacial trauma in our hospital, treatment commences to ensure that airway passages are clear and to replace adequate blood and fluids. However, nasal packing with gauze or Foley catheter is applied when epistaxis was noted. Correction of coagulo- pathy is also needed to be performed. Therefore, if nasal bleeding continued despite anterior and posterior nasal packing, angiography and TAE of carotid artery may detect and control traumatic life-threatening hemorrhage. Saka- moto et al [12] showed that nasal packing or ligation of external carotid artery failed to achieve hemostasis in 72.2% patients, and the bleeder was detected by angio- graphy followed by successful TAE of the branches of the external carotid artery.

Ardekian et al [7] revealed that angiography and TAE to detect and control traumatic epistaxis are not favored, except for gunshot injuries on areas that contain anasto- moses between external and internal carotid system. Barsotti et al [13] showed that the connection increases the risk of embolic material crossing from the external to internal carotid circulation with complications of central nervous system. Complications have been reported in up to 50% of patients, including Cerebrovascular accidents, facial nerve palsy, trismus, tongue tip necrosis, and soft tissue necrosis [4]. Mahmood and Lowe [14] revealed that the incidence of complications is low, including blindness, facial nerve palsy, soft tissue necrosis, and inadvertent migration of embolus into the internal carotid and vertebral arteries.

In conclusion, the incidence of severe hemorrhage resulting from maxillofacial trauma rarely occurs, but it may be life-threatening. When maxillofacial injuries followed by life-threatening hemorrhage occur, airway, breathing, and circulation should be managed first. Nasal packing, correction of coagulopathy, reduction of fractures, and arterial ligation remain the standard treatment for patients with maxillofacial injuries. However, when the methods fail, TAE of carotid artery and its branches can offer a safe alternative to control hemorrhage. Early diagnosis and intervention of life-threatening hemorrhage will improve the prognosis.

Wei-Hsiu Liu MD Yuan-Hao Chen MD Cheng-Ta Hsieh MD En-Yuan Lin MD Tzu-Tsao Chung MD Da-Tong Ju MD

Department of Neurological Surgery Tri-Service General Hospital

National Defense Medical Center, Taipei 114

Taiwan, Republic of China E-mail address: [email protected]

doi:10.1016/j.ajem.2007.07.036

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