Not All Embolizations Are Created Equally in the Management of Posterior Epistaxis: Discussion of Safety Measures Avoiding Neurological Complications

Figure 1

Arterial supply of nasal cavity. Digital subtraction angiography via the common carotid artery shows branches of the external and internal carotid artery (ECA and ICA; 90° LAO). For better understanding of the anatomy some anatomical structures like the nasal conchae, the floor of nasal cavity, nose, and frontobasis are drawn schematically. The major part of blood supply for the nasal cavity is provided via branches of the ECA. Especially the sphenopalatine artery (SPA), and end-branch of the internal maxillary artery (IMA), is the main blood supply for the nasal cavity and for Kiesselbach’s plexus (asterisk). The roof of the nasal cavity is supplied by the anterior ethmoidal artery (AEA) and posterior ethmoidal artery (PEA), which are branches of the ophthalmic artery (OphA), i.e., branches of the internal carotid artery (ICA). The blood supply to the floor of the nasal cavity originates from ascending palatine arteries (APA) from the facial artery (FA) and descending palatine artery (DPA) from IMA. Little supply to Kiesselbach’s plexus comes from the superior labial artery (SLA), an end-branch of the FA. And, finally minor supply to the posterior area of the nasal cavity is provided by the ascending pharyngeal artery (APhA), which originates from the ECA. Note the calcification of proximal ICA (arrow). Also shown are occipital artery (OccA), ophthalmic artery (OPhA), and intracranial arteries like anterior and middle cerebral artery (ACA and MCA). As ICA and ECA both contribute to the blood supply of the nasal cavity sometimes, there are some “dangerous” anastomoses, which can cause blindness or stroke when accidentally embolized during the procedure. These potentially “dangerous” anastomoses include the artery of the foramen rotundum, the middle meningeal artery, the accessory meningeal artery, the ethmoidal arteries, the APhA, and of course the communications between the FA and OPhA[3].