https://orcid.org/0009-0007-0656-800X
Abstract
Penetrating facial trauma can result in vascular abnormalities that are difficult to identify on initial imaging due to artifact from retained fragments. External carotid artery pseudoaneurysms are uncommon but may carry significant morbidity if not promptly recognized. A 34-year-old female presented after a gunshot wound to the left face. Initial computed tomography angiography (CTA) demonstrated left vertebral artery V3 dissection, severe left internal carotid artery stenosis, and a comminuted mandibular fracture with retained ballistic fragments causing substantial streak artifact. Due to persistent concern for vascular injury, craniocervical angiography was performed and revealed distal left vertebral artery occlusion, left internal carotid artery dissection, and a pseudoaneurysm arising from the ascending pharyngeal branch of the external carotid artery. Coil embolization was successfully performed. Occult vascular injury should remain a concern following penetrating facial trauma despite nondiagnostic CTA findings. Early angiographic evaluation may influence management and operative planning.
Introduction
Penetrating maxillofacial trauma carries substantial risk of vascular injury involving the carotid and vertebral arterial systems [1]. Although computed tomography angiography (CTA) has become a first-line imaging modality in the evaluation of penetrating neck and facial trauma, retained ballistic fragments may generate streak artifact that obscures clinically significant vascular injuries and limits diagnostic accuracy [2, 3].
Pseudoaneurysms involving branches of the external carotid artery are uncommon complications of penetrating trauma [4]. Injuries involving the ascending pharyngeal artery are particularly rare due to the vessel’s small caliber and deep anatomical location [4, 5]. Delayed recognition may result in hemorrhage, neurologic complications, airway compromise, or increased operative complexity [4, 5].
We present a case of traumatic ascending pharyngeal artery pseudoaneurysm identified on craniocervical angiography following penetrating facial trauma with retained ballistic fragments and subsequently treated with successful coil embolization.
Case report
A 34-year-old female presented following a gunshot wound to the left side of the face. Initial trauma evaluation demonstrated extensive maxillofacial injury. CTA of the neck revealed left vertebral artery V3 dissection, >80% stenosis of the left internal carotid artery, patent external carotid arteries, and a comminuted fracture involving the left mandibular body and angle. Retained bullet fragments produced significant streak artifact that limited vascular visualization (Figs 1 and 2).
CT head demonstrating extensive streak artifact limiting evaluation of adjacent anatomy and injury.
CTA neck demonstrating extensive streak artifact from retained ballistic fragments limiting vascular assessment.
The patient was initiated on aspirin 81 mg daily due to concern for blunt cerebrovascular injury. Given the mechanism of injury and limitations of CTA imaging, craniocervical angiography was pursued for further evaluation and potential intervention. The patient initially deferred angiographic procedure. However, the patient later agreed to pursue the procedure.
The right common femoral artery was accessed under ultrasound guidance, and digital subtraction angiography of the bilateral carotid and vertebral systems was performed. Angiography demonstrated traumatic occlusion of the distal left vertebral artery at the skull base, a short-segment non-flow-limiting dissection of the left internal carotid artery ~6 cm distal to the bifurcation, and a saccular pseudoaneurysm arising from the ascending pharyngeal branch of the external carotid artery (Fig. 3).
Digital subtraction angiography demonstrating pseudoaneurysm arising from the ascending pharyngeal branch of the left external carotid artery.
A coaxial microcatheter was advanced into the ascending pharyngeal artery, and coil embolization was performed under fluoroscopic guidance. Post-embolization angiography demonstrated complete absence of pseudoaneurysm opacification (Fig. 4). Hemostasis was achieved with an Angio-Seal closure device following catheter removal. The patient tolerated the procedure without complication.
Post-embolization angiography demonstrating absence of pseudoaneurysm opacification following coil embolization.
Discussion
Penetrating craniofacial trauma may result in a broad spectrum of vascular injuries, including arterial dissection, occlusion, active extravasation, arteriovenous fistula formation, and pseudoaneurysm formation [1, 2]. Prompt identification of these injuries is critical due to the risk of delayed hemorrhage, ischemic complications, and challenges associated with operative planning.
CTA has become widely utilized in trauma settings because of its rapid acquisition and noninvasive nature [2, 3]. However, metallic streak artifact from retained ballistic fragments can significantly reduce diagnostic sensitivity, particularly in anatomically complex regions such as the skull base and deep facial spaces [2, 3]. In this patient, initial CTA failed to identify the ascending pharyngeal artery pseudoaneurysm, which was later visualized during formal angiography. Recognition of the pseudoaneurysm before operative facial fracture repair reduced concern for intraoperative hemorrhagic complications.
Pseudoaneurysms involving the ascending pharyngeal artery are rarely reported in the literature [4, 5]. Due to its small caliber and deep anatomical course adjacent to critical neurovascular structures, injury to this vessel may be difficult to identify clinically and radiographically. Endovascular embolization has emerged as an effective minimally invasive treatment strategy for these lesions and may avoid morbidity associated with open surgical exploration [4].
This case highlights the importance of angiographic evaluation despite reassuring CTA findings [6]. Identification of otherwise occult vascular injuries may substantially alter surgical planning and perioperative management, particularly in patients requiring operative repair of facial fractures. Additional reports may help further characterize the incidence and management of external carotid branch pseudoaneurysms following penetrating maxillofacial trauma.
Conclusion
Penetrating facial trauma with retained ballistic fragments may obscure clinically significant vascular injuries on CTA imaging. This case demonstrates discrepancy between CTA and craniocervical angiography for the diagnostic evaluation of penetrating trauma with retained ballistic fragments and resultant streak artifact. In patients with suspicion for vascular injury, craniocervical angiography should be strongly considered despite nondiagnostic CTA findings.
Conflicts of interest
The authors declare no conflicts of interest.
Funding
None declared.
Patient consent for publication
Written informed consent for publication was obtained from the patient.
