Delayed life-threatening bleeding after facial fractures

Following emergent re-admission, his nasal cavity was packed, the jaw unlocked, and he was taken immediately to the catheter lab where an angiogram was done. Baseline angiogram showed multiple sites suspicious for arterial injuries caused by the LeFort II fracture involving bilateral distal internal maxillary arteries and branches thereof (Fig 1, 2). In addition, a pseudoaneurysm was found on the left descending palatine artery (Fig 1).

Figure 1. Lateral view, right common carotid artery (A1, A2 magnified) and left external carotid artery (B1, B2 magnified) injections. Contrast extravasation from vascular trauma cause by facial fractures (LeFort II) involving both distal internal maxillary arteries (IMA, arrows) and development of a pseudoaneurysm along the left deep palatine artery (DPA, yellow circle). Internal carotid artery (ICA), facial artery (FA).

Figure 2. Lateral view, right common carotid artery (A1, A2) and left external carotid artery (B1, B2) injections. Arterial phase (A1, B1) and late arterial phase (A2, B2). Multifocal small contrast extravasation from vascular trauma cause by facial fractures (LeFort II) along bilateral infraorbital (IOA) and deep palatine (DPA) arteries suspected in late arterial phase (solid yellow and white circles). Internal carotid artery (ICA), facial artery (FA).

These vascular pathologies were considered potential injuries and sources of bleeding. The patient underwent embolization of both distal internal maxillary arteries and distal facial arteries (Fig 3). The remaining hospital course was unremarkable.

Figure 3. Lateral view, left external carotid artery injection, status post embolization of distal internal maxillary artery (remaining stump, yellow asterisk) and facial artery (cut off, arrow). There is no filling of the pseudoaneurysm (see Fig 1). Increased collateral flow via the transverse facial artery (TFA). Jaw wiring post facial fractures (dashed box).

Treatment Considerations
Delayed bleeding from facial fractures [1] is uncommon and can be life-threatening [2]. It is often associated with medium-sized vessel trauma which can also lead to the development of pseudoaneurysms [3,4]. The bleeding is often extremely brisk, bright red, and episodic. This type of bleeding is thought to stop abruptly because platelets are activated by the high sheer stress at the site of the vascular injury. However, this platelet plug is not durable and additional bleeding can be expected.

Although active bleeding is rarely seen during angiography, emergent treatment is indicated, e.g. endovascular embolization of suspected arterial bleeding sources, to prevent future bleeding events. These bleeds are often related to vascular injuries from fractures in the bones in which the arteries are embedded or lie adjacent to. This is thus, like the more classic epidural hematoma related to a skull fracture and a damaged middle meningeal artery.

A pseudoaneurysm is an aneurysm that has no media and may also be missing the adventitia and the intima. In these cases, the blood is held within this cavity by the surrounding blood clot, or tissue. Pseudoaneurysms do not heal spontaneously, and treatment is usually required.

References

1. Frakes MA, Evans T. Evaluation and management of the patient with LeFort facial fractures. J Trauma Nurs. 2004 Jul-Sep. 11(3):95-101. https://europepmc.org/article/med/16512269
2. Kelts G, Maturo S, Couch ME, Schmalbach CE. Blunt cerebrovascular injury following craniomaxillofacial fractures: a systematic review. Laryngoscope. 2017 Jan. 127 (1):79-86. https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.26186
3. Bozkurt M, Kapi E, Karakol P, Yorgancilar E. Sudden rupture of the internal maxillary artery causing pseudoaneurysm (mandibular part) secondary to subcondylar mandible fracture. J Craniofac Surg. 2009 Sep. 20(5):1430-2. https://pubmed.ncbi.nlm.nih.gov/19816273/
4. Hwang K, Choi HG. Bleeding from posterior superior alveolar artery in Le Fort I fracture. J Craniofac Surg. 2009 Sep. 20(5):1610-2. https://www.semanticscholar.org/paper/Bleeding-from-posterior-superior-alveolar-artery-in-Hwang-Choi/07e30e1d397eeba780194d7150037b3f682635b3