Internal Maxillary Artery Embolization for Successful Treatment of Orbital Compartment Syndrome After Penetrating Gunshot Trauma

Introduction: A 23-year-old man who sustained penetrating gunshot trauma to the right side of his face resulting in multiple comminuted facial and orbital fractures and overt arterial injury leading to the development of orbital compartment syndrome (OCS) of the right eye. The right pupil was dilated to 4 mm and non-reactive with only limited light perception. Handheld tonometer did not register an intraocular pressure (IOP) in the right eye, indicating dangerously elevated IOP. After an emergent bedside lateral canthotomy and inferior and superior cantholysis the right eye IOP was subsequently measured to be dangerous high, 50 mmHg. CT angiography showed active contrast extravasation in the right pterygoid muscle likely from the right internal maxillary artery (IMA), with hemorrhage into the right maxillary sinus.

Methods: We performed endovascular coil embolization of a distal branch of the IMAX for treatment of orbital compartment syndrome caused by penetrating gunshotwound.

Results: A large internal maxillary pseudoaneurysm was confirmed on digital subtraction angiography and the patient underwent transarterial coil embolization and proximal vessel sacrifice of the internal maxillary artery with obliteration of the pseudoaneurysm. Post coiling angiographic runs demonstrated complete elimination of distal anterograde flow through the IMA without further evidence of contrast extravasation. Post operatively, the right pupil was reactive. Serial tonopen examinations showed a resolution of elevated IOP down to 16mm Hg without any additional IOP lowering eye drops. Visual acuity examination showed 20/400 vision in the right eye.

Conclusion : The patient’s facial and orbital fractures allowed for direct communication between the maxillary sinus and the orbit. This presented a unique opportunity for sight-saving endovascular treatment of the transected IMA to treat OCS. Treatment of the IMAX pseudoaneurysm was successful in controlling hemorrhage from the penetrating wound and led to return of optic nerve function with progressive improvement in vision and resolution of the patient’s OCS.