1. Consideration of Vascular Anatomy on Endovascular Treatment of Intractable Oronasal Bleeding ASNR 2016, Washington
1Sung Won YOUN, 2Hui Joong Lee
Dept. of Radiology, 1Catholic Univ. of Daegu,
2Kyungpook National Univ., Korea

2. We declare that we have no conflict of interest.

3. Purpose
Severe craniofacial injury or tumor may cause intractable oronasal bleeding, which is refractory to conventional treatments.
The main focus of this presentation is to discuss comprehensive understanding for head and neck anatomy related with interventional procedures.

4. Material and Methods
12 patients between the ages of 19 and 67 years who had intractable oronasal bleeding resulting from severe craniofacial injuries or tumor received treatments of transarterial embolization using pledget of Gelfoam, N-Butyl 2-Cyanoacrylate (NBCA), or platinum coils. We then reviewed their clinical and neuroradiologic anatomy retrospectively. In all cases, intractable oronasal bleeding was controlled. In a few cases, embolization technique should be performed to prevent or control bleeding related with tumor itself or operation. As some arteries of head and neck have dangerous anastomosis with intracranial vessels, radiologists have to comprehensive understanding for head and neck anatomy.

5. Table 1. Characteristics of Patients

6. Case 1. Pan facial bone fracture (Le fort II fracture & mandible fracture) A 19-year-old man with epistaxis refractory to nasal packing. (A) CT scan of the face shows multiple fractures of turbinates (arrows). Left internal maxillary angiography (B) and super selective angiogram (B: anterior posterior projection, C: lateral projection) carotid injection shows extravasation of the contrast material from the lateral branch of sphenopalatine artery (arrow head). Medial or septal branches supply septum (arrow), and lateral branches supply turbinates (arrow head). A B C D

7. Case 2. Trauma, lateral branch of sphenopalatine artery, a 53-year-old man. (A) CT scan of the face shows Le Fort II facial fractures (arrows) involving pterygopalatine fossa (open arrow). (B) Right external carotid injection (lateral view) shows dissection of internal maxillary artery (arrow) with extravasation of contrast(open arrow).

8. Case 3. Trauma Medial branch of sphenopalatine artery, a 19-year-old man. (A) CT scan of the face shows multiple fractures of the maxilla (arrows) and right temporal bone (arrowheads). (B) Right external carotid injection (anterior-posterior view) shows extravasation of the contrast material from the lesser palatine artery, the medial or septal branch of the sphenopalatine artery (arrow), the anterior deep temporal artery, and the inferior alveolar artery.

9. Case 6 Maxillary carcinoma post-operation and post radiation, a 56-year-old man. (A) MR scans of the face show enlarged vascular structure in destructed posterior portion of right maxillary sinus. (B) Right external carotid injection (anterior-posterior view) shows extravasation of the contrast material from the lesser palatine artery (long arrow), the septal branch of the sphenopalatine artery (arrowhead), the anterior deep temporal artery (short arrow), and the inferior alveolar artery (open arrow).
박종대

10. Case 7. Zygomaticomaxillary fracture, a 19-year-old man
Case 7. Zygomaticomaxillary fracture, a 19-year-old man. The infraorbital artery (arrow) is an artery in the head that branches off the maxillary artery, emerging through the infraorbital foramen, just under the orbit of the eye.

11. Case 9. Tongue bite, a 38-year-old man with hemophilia
Case 9. Tongue bite, a 38-year-old man with hemophilia. (A) CT scan of the oral cavity shows mixed densities lesion of the tongue base (arrow). (B) Selective angiography (lateral view) of right lingual artery (arrow) shows extravasation of the contrast material from the dorsum of tongue (open arrow). Faint facial artery (double arrows) communicates with facial artery via submandibular artery so called perigrandular ring (Linguofacial collateral pathway) (arrow head). Repeated bleeding (C and D) was cured by embolization. A B C D

12. Case 10. Pleomorphic adenoma, a 67-year-old man
Case 10. Pleomorphic adenoma, a 67-year-old man. (A) CT scan of neck shows retropharyngeal mass (arrows). (B) Right external carotid injection (lateral view) shows extravasation of the contrast material from the pharyngeal branch (arrow) of ascending pharyngeal artery. musculospinal a (open arrow), neuromeningeal trunk (double arrows), inferior pharyngeal artery (large arrow)

13. Case 11. Hypopharyngeal carcinoma, a 74-year-old man
Case 11. Hypopharyngeal carcinoma, a 74-year-old man. (A) Contrast enhanced neck CT scan shows enhancing mass filling pyriform sinus(arrows) with multiple lymph node metastasis. (B) Right common carotid injection (anterior-posterior view) shows extravasation of the contrast material from the superior laryngeal artery (arrow). (C) After super selection of superior laryngeal artery, ectatic pseudoaneurysm (arrow) was embolized by NBCA.

14. Case 12. Mouth floor carcinoma, a 42-year-old man
Case 12. Mouth floor carcinoma, a 42-year-old man. (A) MRI shows dense contrast enhancement in the floor of the mouth. (B) Post op CT shows bone defect of body of mandible. Selective angiography for submental artery, a branch of facial artery (C: AP; D: lateral) show contrast extra vasation into oral cavity.

15. Case 13. Nasopharyngeal carcinoma, a 31-year-old man
Case 13. Nasopharyngeal carcinoma, a 31-year-old man. (A) CT scan of the face shows bony destruction of petrous apex and some portion of middle cranial fossa (arrows). (B) Right external carotid injection (right oblique view) shows extravasation from petrous segment of internal carotid artery.

16. Case 14. Spontaneous bleeding in a 42-year-old man with liver cirrhosis. Right external carotid injection shows extravasation of the contrast material from the medial or septal branch of the sphenopalatine artery (arrow)

17. Considerations; ECA has eight branches; 1. superficial temporal a. 2
Considerations; ECA has eight branches; 1. superficial temporal a. 2. internal maxillary a.3. ascending pharyngeal a.4. occipital a. 5. posterior auricular a 6. lingual a.7. facial a. 8. superior thyroid a.“As some arteries of head and neck have dangerous anastomosis with intracranial vessels, … …”
1. superficial temporal a. >> none
2. internal maxillary a. Vidian A, ILT
3. ascending pharyngeal a. Neuromeningeal branch
4. occipital a. >> none
5. posterior auricular a >> none
6. lingual a.>> none
7. facial a. >> otphalmic artery
8. superior thyroid a. >> none

18. In conclusion, endovascular treatment with comprehensive understanding for head and neck vascular anatomy is an acceptable treatment for intractable oronasal bleeding associated with severe craniofacial injuries or tumor when conventional treatments have failed.