Successful Endovascular Treatment of Delayed Spontaneous Intracranial Internal Carotid Artery Blowout Following Orbital Exenteration and Radiation

Most head and neck cancers require aggressive surgical resection followed by external beam radiation therapy. The carotid artery can be injured by surgery or radiation resulting in a delayed “blowout.” A patient who had undergone orbital exenteration for a lacrimal adenoid cystic carcinoma (ACC) followed by external beam radiation presented 16 years later with arterial bleeding from the orbit caused by “blowout” of the cavernous internal carotid artery (ICA). We review the literature on carotid blowout syndrome (CBS) and treatment. The patient was emergently transferred to a hybrid operating room and underwent a balloon occlusion test (BOT) and endovascular sacrifice of the ICA with no neurological deficits postoperatively. Emergent endovascular embolization is an effective treatment for an intracranial ICA blowout in this first reported case of a blowout through the orbit. Elevated radiation dose and lack of tissue coverage may put the cavernous ICA at risk for this delayed complication.