MASSIVE POSTERIOR EPISTAXIS SECONDARY TO A SPHENOPALATINE ARTERY PSEUDOANEURYSM: CASE REPORTS

Abstract

DOI: https://doi.org/10.46296/yc.v10i19.0964

Abstract

Background: Sphenopalatine artery (SPA) pseudoaneurysm is an exceptional but potentially life-threatening cause of massive or recurrent posterior epistaxis. It has been described after facial trauma, endonasal/transsphenoidal and orthognathic procedures, and less commonly after oncologic treatment, radiation, or spontaneously. Objective: To synthesize the clinical presentation, etiologic context, diagnostic work-up, treatment, and outcomes of published cases of epistaxis associated with SPA pseudoaneurysm. Methods: A systematic review was conducted through August 30, 2026 using MEDLINE/PubMed, OpenAlex, publisher/journal searches, and backward/forward citation tracking. Case reports and case series were eligible when an SPA pseudoaneurysm was demonstrated by imaging/angiography and epistaxis was clinically documented. Non-SPA lesions, arteriovenous fistulas without a pseudoaneurysmal component, isolated arterial rupture without pseudoaneurysm, and reports without a documented epistaxis phenotype were excluded. Reporting quality was examined with the JBI Critical Appraisal Checklist for Case Reports. Results: Twenty-six publications comprising 31 patients were included. Orthognathic/craniofacial surgery was the most frequent context (12/31; 38.7%), followed by facial trauma (8/31; 25.8%) and transsphenoidal pituitary surgery (5/31; 16.1%). Among 26 patients with reported age, the median was 29 years (range 13–90). In 22 cases with quantifiable timing, the median interval to clinically relevant bleeding was 13 days (range 4–63). The typical presentation was unilateral, delayed or recurrent posterior epistaxis, often resistant to nasal packing. Digital subtraction angiography was the definitive modality in most reports and enabled treatment during the same session. Endovascular treatment was attempted in 30/31 patients (96.8%) and provided definitive hemostasis in 28/31 (90.3%); three patients ultimately required surgical control. No death attributable to the pseudoaneurysm or its treatment was identified among cases reporting outcomes. Conclusions: Recurrent or massive posterior epistaxis after trauma or surgery involving the pterygopalatine region should trigger early suspicion of SPA pseudoaneurysm. CTA can facilitate localization in stable patients, but selective angiography remains the key diagnostic-therapeutic modality. Superselective embolization is the dominant treatment strategy in the published literature, while surgery remains an important rescue option when embolization fails, is contraindicated, or is unavailable.

Keywords: posterior epistaxis; pseudoaneurysm; sphenopalatine artery; embolization; angiography; hemorrhage; orthognathic surgery; facial trauma.