Nasal Extrusion of Internal Carotid Artery Coil in the Setting of Osteoradionecrosis: A Case Report

Introduction: Internal carotid artery injury is a rare, but potentially devastating sequelae from degenerative changes associated with osteoradionecrosis of the skull base. When encountered, it requires urgent intervention, often through a multidisciplinary approach. Surgical control or embolization by interventional radiologists are the two options for treatment. Both options have significant short or long term complications. We present a unique case of a 55 year old male patient with a long term complication after endovascular embolization and coiling of internal carotid artery.

Case Description: Our patient is a 55-year-old Caucasian male with history of squamous cell carcinoma of his left maxillary sinus status post extended total maxillectomy and two courses of radiation therapy 11 years back. He presented to our tertiary care center with brisk, sentinel bleeding from prior resection site. CT angiography revealed no vascular abnormalities or aneurysms. Endoscopic examination under anesthesia did not show any recurrence but revealed frank devascularization and necrosis of remaining clivus, sphenoid bones and surrounding tissues, suggestive of long-standing osteoradionecrosis. The suspected source of the sentinel bleeding was found to be paraclival segment of the left internal carotid artery and patient underwent interval coiling of the left internal carotid artery by interventional radiology. 18 months later on follow up, a ‘hard wire’ was encountered during his routine care of maxillary defect. Patient had pulled a portion of the wire out through his nasal cavity and clipped it out. This wire was found to be the coil used to occlude his left internal carotid artery. The remaining coil was grossly visualized at the skull base during the visit. Imaging studies confirmed continued occlusion of the artery without evidence of ischemia. No further intervention was done to manipulate the coil and patient experienced no further episodes of significant bleeding.

Discussion and Conclusion: Extrusion of a coil is a rare complication of endovascular arterial intervention. If encountered in a patient whose artery has not fully embolized after intervention, it could potentially be fatal. In the head and neck, it has been described once to occur through the nasal cavity. It has also been described to occur through the middle ear, neck, and oropharynx. Clinicians should be cognizant of subsequent complications with endovascular intervention for arterial bleeding or pseudoaneurysm especially in patient with osteoradionecrosis. Urgent follow-up or intervention should be pursued if this suspected. Effort should be made to educate patients of this complication and they should be strongly advised not to manipulate a coil that could be extruding. Further investigation is necessary to fully quantify the occurrence of coil extrusion and to standardize treatment.