Spontaneous Paraclinoid Carotid Artery Bleeding Presenting as Massive Epistaxis: A Case Report and Literature Review.

Fungal pseudoaneurysms of the internal carotid artery (ICA) are rare, life-threatening complications of invasive fungal sinusitis, particularly in immunocompromised patients. These pseudoaneurysms typically occur in the cavernous segment due to its proximity to the sphenoid sinus and often present with massive epistaxis or neurological deficits. The supraclinoid ICA segment is a rare location for these aneurysms and carries risks of both intracranial and sinonasal hemorrhage. This case report presents an 82-year-old immunocompromised male who experienced sudden massive epistaxis and hemoptysis. Initial CT imaging showed left sphenoid sinus opacification and bony erosion near the paraclinoid ICA, while endoscopy confirmed fungal growth identified as Aspergillus. After surgical debridement, the patient suffered recurrent hemorrhage, prompting CT angiography that revealed a pseudoaneurysm in the supraclinoid segment of the left ICA. Balloon occlusion testing confirmed adequate collateral flow, facilitating endovascular coil embolization. Although initial bleeding was managed, the patient later developed right hemiparesis and ultimately succumbed to complications, including myocardial infarction and aspiration pneumonia. This case underscores the importance of early recognition, urgent vascular imaging, and prompt multidisciplinary intervention in managing this critical condition.