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J Neurol Surg B Skull Base
DOI: 10.1055/a-2607-5667
Review Article

Management Challenges of Internal Carotid Artery Pseudoaneurysm in Skull Base Osteomyelitis

Arun G. Karthat
,
Katti B. Sara
1   Department of Otolaryngology, Christian Medical College, Vellore, India
,
Miria Mathews
1   Department of Otolaryngology, Christian Medical College, Vellore, India
,
Nandu Sukumaran
1   Department of Otolaryngology, Christian Medical College, Vellore, India
,
Santhosh B. Kannan Bharathy
2   Department of Interventional Radiology, Christian Medical College, Vellore, India
,
Aeesha Tasneem
1   Department of Otolaryngology, Christian Medical College, Vellore, India
,
Abi Manesh
3   Department of Infectious Disease, Christian Medical College, Vellore, India
,
Shyamkumar N. Keshava
2   Department of Interventional Radiology, Christian Medical College, Vellore, India
,
Rajan Sundaresan
1   Department of Otolaryngology, Christian Medical College, Vellore, India
,
Regi Thomas 
1   Department of Otolaryngology, Christian Medical College, Vellore, India
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Abstract

Background

Skull base osteomyelitis is a potentially life-threatening infection typically seen in elderly diabetic or immunocompromised patients. Internal carotid artery pseudoaneurysm caused by skull base osteomyelitis is a very rare complication. We present here three such instances to share our clinical experience and insights gained in the management of these cases.

Methods and Results

A retrospective clinical audit of 142 skull base osteomyelitis patients (January 2010–May 2023) revealed three cases complicated by pseudoaneurysm at the cervicopetrous junction, with Pseudomonas being the primary causative organism. Two patients underwent successful endovascular coiling and survived after prolonged antipseudomonal therapy. A literature review of 12 similar cases also showed Pseudomonas as the dominant pathogen, whereas 1 case each was caused by tuberculosis and fungal infection. Most patients received antimicrobial therapy for more than 3 months. Follow-up data were unavailable for seven patients; among the remaining cases, all survived except one.

Conclusion

Internal carotid artery mycotic pseudoaneurysm is a rare yet potentially devastating complication of skull base osteomyelitis. Timely diagnosis and aggressive treatment are crucial to prevent catastrophic outcomes. Endovascular therapy has emerged as the primary modality for the management of these aneurysms. In the absence of surgical debridement for treatment of skull base osteomyelitis, prolonged antimicrobial therapy (at least 3 months) is essential.

Keywords

skull base osteomyelitis - carotid pseudoaneurysm - mycotic aneurysm - epistaxis

Data Availability Statement

The data supporting the findings of this study are available upon request from the authors. The data are not publicly available due to privacy or ethical restrictions.


Ethical Statement

All patients consented for the study, and institutional review board approval was taken for the same (IRB number: 15066 [OBSERVE] dated: December 14, 2022).




Publication History

Received: 20 February 2025

Accepted: 12 May 2025

Article published online:
30 May 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Hamiter M, Amorosa V, Belden K. et al. Skull base osteomyelitis: historical perspective, diagnosis and management update. Otolaryngol Clin North Am 2023; 56 (05) 987-1001
    PubMedSearch in Google Scholar
  • 2 Sharma PK, Garisa SS, Kumaran SV, Varma S. Mycotic (infected) pseudoaneurysm, a diagnostic challenge - case series. J Clin Imaging Sci 2020; 10: 86
    PubMedSearch in Google Scholar
  • 3 Baker A, Rizk H, Carroll W, Lambert P. Cervical internal carotid artery pseudoaneurysm complicating malignant otitis externa: first case report. Laryngoscope 2015; 125 (03) 733-735
    PubMedSearch in Google Scholar
  • 4 Maguire EM, Pearce SWA, Xiao R, Oo AY, Xiao Q. Matrix metalloproteinase in abdominal aortic aneurysm and aortic dissection. Pharmaceuticals (Basel) 2019; 12 (03) 118
    PubMedSearch in Google Scholar
  • 5 Mascitelli JR, De Leacy RA, Oermann EK. et al. Cervical-petrous internal carotid artery pseudoaneurysm presenting with otorrhagia treated with endovascular techniques. J Neurointerv Surg 2015; 7 (07) e25-e25
    PubMedSearch in Google Scholar
  • 6 Budhiraja S, Sagar P, Kumar R, Sharma SC. Mycotic pseudoaneurysm of internal carotid artery induced by skull base osteomyelitis. Otol Neurotol 2019; 40 (08) e816-e819
    PubMedSearch in Google Scholar
  • 7 Kreicher KL, Hatch JL, Lohia S, Meyer TA. Propionibacterium skull base osteomyelitis complicated by internal carotid artery pseudoaneurysm. Laryngoscope 2017; 127 (10) 2337-2339
    CrossrefPubMedSearch in Google Scholar
  • 8 Charan BD, Thanneru S, Sebastian LJD, Jain S. Reconstructive endovascular treatment of petrous ICA pseudoaneurysm in skull base osteomyelitis: a hidden catastrophe. BMJ Case Rep 2024; 17 (02) e258539
    CrossrefPubMedSearch in Google Scholar
  • 9 Lau JSK, Wong JCY, Ng RYT, Pang VKY, Wong CK. Malignant otitis externa complicated by multiple cervical-petrous internal carotid artery pseudoaneurysms: a case report. Hong Kong Med J 2019; 25 (02) 152-155
    PubMedSearch in Google Scholar
  • 10 Saket RR, Hetts SW, Tatum JK, Glastonbury CM. CT and MRI findings of sphenoid sinus internal carotid artery pseudoaneurysm: an important and challenging differential diagnosis for a skull base mass. Clin Radiol 2012; 67 (08) 815-820
    PubMedSearch in Google Scholar
  • 11 Teng MMH, Nasir Qadri SM, Luo CB, Lirng JF, Chen SS, Chang CY. MR imaging of giant intracranial aneurysm. J Clin Neurosci 2003; 10 (04) 460-464
    PubMedSearch in Google Scholar
  • 12 Lehman VT, Brinjikji W, Mossa-Basha M. et al. Conventional and high-resolution vessel wall MRI of intracranial aneurysms: current concepts and new horizons. J Neurosurg 2018; 128 (04) 969-981
    PubMedSearch in Google Scholar
  • 13 Ruff MW, Nasr DM, Klaas JP, Renaud DL. Internal carotid artery pseudoaneurysm and ischemic stroke secondary to retropharyngeal and parapharyngeal abscess. J Child Neurol 2017; 32 (02) 230-236
    CrossrefPubMedSearch in Google Scholar
  • 14 Mohit AA, Sekhar LN, Natarajan SK, Britz GW, Ghodke B. High-flow bypass grafts in the management of complex intracranial aneurysms. Neurosurgery 2007; 60 (2, Suppl 1): ONS105-ONS122 , discussion ONS122–ONS123
    PubMedSearch in Google Scholar
  • 15 Santhosh Babu KBM, Kumar Muthukumar M, Vinu Moses M, Aparna Irodi M, Leena Robinson Vimala M, Regi Kurien M. et al. Role of endovascular interventions in the management of COVID-19 patients presenting with massive hemorrhage: a single-center experience. Vasc Dis Manag 2022; 19 (08) E122-E128
    PubMedSearch in Google Scholar
  • 16 Mendez AA, McCarthy DJ, Tonetti DA. et al. Angiographic predictors of outcomes after balloon test occlusion. Stroke Vasc Intervent Neurol 2022; 2 (06) e000371
    PubMedSearch in Google Scholar
  • 17 Seshadri H, Saraf R, Barchha S. Radiological findings and endovascular management of internal carotid artery pseudoaneurysm in the setting of mucormycosis and COVID-19. BJR Case Rep 2023; 10 (01) uaad006
    PubMedSearch in Google Scholar
  • 18 Deshmukh AS, Priola SM, Katsanos AH. et al. The management of intracranial aneurysms: current trends and future directions. Neurol Int 2024; 16 (01) 74-94
    PubMedSearch in Google Scholar
  • 19 Kadkhodayan Y, Shetty VS, Blackburn SL, Reynolds MR, Cross III DT, Moran CJ. Pipeline embolization device and subsequent vessel sacrifice for treatment of a bleeding carotid pseudoaneurysm at the skull base: a case report. J Neurointerv Surg 2013; 5 (05) e31-e31
    PubMedSearch in Google Scholar
  • 20 Thomas R. Targeted skull base biopsies in the management of central skull base osteomyelitis. Clin Otolaryngol 2021; 46 (01) 72-74
    CrossrefPubMedSearch in Google Scholar
  • 21 Yagci AB, Ardiç FN, Oran I, Bir F, Karabulut N. Ruptured petrous carotid pseudoaneurysm due to tuberculous otitis: endovascular treatment. Interv Neuroradiol 2006; 12 (01) 53-56
    PubMedSearch in Google Scholar
  • 22 Cho HJ, Son W, Lee J, Jung DJ. Internal carotid artery pseudoaneurysm secondary to skull base osteomyelitis: a case report. J Audiol Otol 2022; 26 (01) 50-54
    PubMedSearch in Google Scholar
  • 23 Németh T, Szakács L, Bella Z, Majoros V, Barzó P, Vörös E. The treatment of pseudoaneurysms with flow diverters after malignant otitis externa. Interv Neuroradiol 2017; 23 (06) 609-613
    PubMedSearch in Google Scholar
  • 24 Hassannia F, Carr SD, Yu E, Rutka JA. Internal carotid artery aneurysm in skull base osteomyelitis: does the pattern of cranial nerve involvement matter?. J Laryngol Rhinol Otol 2018; 132 (10) 929-931
    PubMedSearch in Google Scholar
  • 25 Tanaka H, Patel U, Shrier DA, Coniglio JU. Pseudoaneurysm of the petrous internal carotid artery after skull base infection and prevertebral abscess drainage. AJNR Am J Neuroradiol 1998; 19 (03) 502-504
    PubMedSearch in Google Scholar