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FIG 2. Illustrative case 2 of the spectrum of rCBS and its management.
A and B, Sixty-six-year-old woman (patient CH) initially presents with CBS (Group 3). Lateral views from superselective injection of a facial arterial branch (short arrow) in early (A) and late arterial phases (B) show a ruptured pseudoaneurysm with extensive extravasation (long arrows). This successfully was treated with coil embolization.
C, Twenty-one days later, the patient develops a second episode of CBS (Group 1) due to a flap dehiscence. Oblique view from right CCA injection shows no evidence of pseudoaneurysm and prior ligation of the ECA. The patient failed BTO at this time, prompting a flap revision.
D, Seventeen days later, the patient develops a third episode of CBS (Group 3). Oblique view from right CCA injection shows a large pseudoaneurysm of that vessel. Acute hemorrhage initially was arrested by placement of two overlapping 8 x 20-mm Wallstents across the rent of the artery (not shown).
E and F, One day later, the patient develops a fourth episode of CBS (Group 3) due to a TF of the previously deployed stents. After inflation of a balloon occlusion catheter across the carotid rent, the pseudoaneurysm was directly punctured and embolized with cyanoacrylate. Fluoroscopic spot film (E) and subtracted-control angiography (F) from right CCA injection (oblique view) shows complete obliteration of the pseudoaneurysm with cyanoacrylate (arrow) and patency of the parent artery.
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