A 16-month-old child presented with episodes of epistaxis and intermittent fever. CT angiogram and digital subtraction angiography revealed a large pseudoaneurysm arising from the left internal carotid artery with no distal flow. Coil embolization was performed to occlude the pseudoaneurysm and left internal carotid artery, resulting in complete occlusion and no subsequent epistaxis, though mild right hemiparesis developed. This case describes a rare presentation of an extracranial internal carotid artery pseudoaneurysm in a toddler without a history of trauma or infection.

1. Rare presentation of extracranial ICA pseudoaneurysm in a
16-month-old child
Ariharan K, JIPMER.

2. Clinical presentation
• 16-month-old child with single episode of epistaxis (about 100 ml) and
intermittent high grade fever.
• Examination – hypertension. Epistaxis was attributed to it.
• Following 2 more episodes of epistaxis, CT angiogram was done.
• CT Angiogram - large pseudoaneurysm from left ICA
- no distal flow
- hematoma in left parapharyngeal space
• Left ICA and MCA - filling from contralateral ICA
- through anterior communication artery
• No obvious infarct was made out.

3. Digital subtraction angiography (DSA)
• DSA - left ICA - slow filling pseudoaneurysm with narrow neck from left cervical ICA
- no flow in left ICA distal to the pseudoaneurysm
• Right ICA injection - normal filling of bilateral MCA and ACA.

4. DSA
• Coil embolization of left ICA (Nestermicro
embolization coil) was done
• Post procedure DSA - complete occlusion of the
pseudoaneurysm and left ICA
• No subsequent epistaxis.
• Neurological examination - mild right hemiparesis.

5. Discussion
• Extracranial ICA pseudoaneurysms are rare in children.
• Usual causes - infections and trauma.
• Clinical presentation - neck mass, stroke or epistaxis.
• Treatment options - coil embolization, vascular plugs, glue injection and
surgical occlusion1,2.
• This report describes an unusual presentation of an extracranial ICA
pseudoaneurysm in a toddler without trauma or local infection
• Youngest reported extracranial ICA pseudoaneurysm - 10 month old by
Tannuri et al. in 2003 secondary to neck space infection3.
• In children presenting with epistaxis, extracranial vessel pseudoaneurysm
should be considered in the differential diagnosis.

6. References
1. Sundarrajan, C., Isa, S.A., Caruso, J.P. et al. Treatment of large infectious extracranial carotid artery
pseudoaneurysms in children: a systematic review of the literature. Childs Nerv Syst. 2021 Feb;10.
https://doi.org/10.1007/s00381-021-05084-0
2. Jagetia A, Sharma D, Singh D et al. Endovascular Occlusion of Cervical Internal Carotid Artery
Pseudoaneurysm in a Child Treated by N-Butyl Cyanoacrylate: A Rare Case Report. Pediatr Neurosurg
2015;50:168-172. doi: 10.1159/000381861
3. Tannuri U, De Almeida NM, Piske R et al. Giant pseudoaneurysm of the internal carotid artery causing
upper airway obstruction in a 10-month-old infant treated by endovascular occlusion and surgical
drainage. J Pediatr Surg. 2003 Sep;38(9):1393-5. doi: 10.1016/s0022-3468(03)00404-4