Carotid artery pseudoaneurysm after orthognathic surgery causing lower cranial nerve palsies: endovascular repair.

PURPOSE: Reported complications following Le Fort osteotomies are rare but can include epistaxis from disruptions or pseudo-aneurysms of the maxillary artery or its distal branches the descending palatine and sphenopalatine arteries, aseptic necrosis of the maxilla, ophthalmic injuries including blindness, ophthalmoplegia, and keratitis sicca, and arteriovenous fistulas or false aneurysms of the carotid arteries (external and/or internal). The mechanism of injury to neurovascular structures can be the result of direct or indirect trauma, such as injuries from surgical instruments, traction injuries during manipulation of the osteotomized bone segments or during inadvertent manipulations of the head and neck, or from fractures extending to the base of the skull, orbit, or pterygopalatine fossa associated with the pterygomandibular dysjunction or maxillary downfracture.

CASE REPORT: An 18 year-old male with facial bone dysplasia, apertognathia, maxillary hypoplasia and mandibular hyperplasia was treated with maxillary Le Fort I osteotomy with internal fixation and elastic intermaxillary fixation. Following surgery, the patient developed palsies of the vagus and accessory nerves manifesting as dysphagia, cough, vocal cord paralysis and trapezius muscle atrophy. Cross sectional imaging revealed a small, laterally pointing pseudoaneurysm of the high cervical internal carotid artery (ICA) at the skull base, exerting pulsatile mass effect on adjacent lower cranial nerves. The patient was treated with carotid artery stent reconstruction and pseudoaneurysm coil obliteration, and kept on dual antiplatelet therapy for two months. Partial recovery from cranial nerve palsies was observed within a year.

CONCLUSION: A small, broad-based, laterally-pointing ICA pseudoaneurysm at the exit of the carotid canal without surrounding hematoma was clearly demonstrated on CTA, which visualization was difficult on MRA due to considerable metallic artifact from surgical hardware. Angiography exquisitely demonstrated the pseudoaneurysm, which was fully repaired with the combination of stenting and coil obliteration, allowing total preservation of the ICA.