Rian Holayter, MD – Attending Physician, Interventional Radiology, University of Louisville Hospital; Nicholas Kemper, BS – Medical Student, University of Louisville School of Medicine; Clinton Tyler, BS – Medical Student, University of Louisville School of Medicine
Purpose: Severe maxillofacial trauma and bleeding can occur in the context of a high-speed motor vehicle collision, leading to significant morbidity and mortality. Primary survey with prompt control of airway, breathing, and circulation is critical. Hemorrhage control is primarily obtained through pressure packing, manual reduction, and balloon tamponade. Options for refractory hemorrhage include surgical ligation or trans-arterial embolization . Here we present a case of refractory hemorrhage with hemodynamic instability requiring massive transfusion protocol and trans-arterial embolization of an external carotid artery pseudo-aneurysm, which we posit for use in such cases of hemorrhage that are otherwise difficult to access.
Material and Methods: Retrospective chart review was performed with special attention to surgical interventions, imaging results, and overall clinical course.
Results: A 29-year-old male presented following a high-speed motor vehicle collision with minor facial abrasions and deformities of the left lower extremity and right wrist. The patient was initially hemodynamically stable with a Glascow coma score (GCS) of 15 but subsequently declined clinically, developing frank hemorrhage through the left external auditory canal with associated hypotension, tachycardia, and agitation. Hemotympanum was initially managed with Rhino Rocket (Summit Medical, St. Paul, Minnesota) and initial CT revealed a contrast collection posterior to the left mandibular ramus concerning for either pseudo-aneurysm or contained extravasation of the left external carotid artery. The patient was promptly sent to Interventional Radiology, where fluoroscopy revealed active extravasation from the left internal maxillary and superficial temporal arteries, which underwent successful coil embolization.
Conclusions: Severe maxillofacial trauma is a potentially life-threatening injury that poses tremendous risk to regional structures and can eventually result in neurological damage. Management requires a multifaceted approach between several clinical departments and prompt airway and hemorrhage control. As emphasized in this case, Interventional Radiology plays a critical role in such cases by offering trans-arterial embolization as a treatment option for refractory hemorrhage.