Iatrogenic pseudoaneurysm formation in the medial orbitofrontal artery following rhinoplasty and nasal osteotomy: A case report

Abstract

Background:

Intracranial vascular complications following rhinoplasty are exceptionally rare but may result in devastating neurological outcomes. We report a rare case of iatrogenic pseudoaneurysm of the medial orbitofrontal artery after rhinoplasty with nasal osteotomy.

Case Description:

A 31-year-old man presented with postoperative intracerebral hemorrhage shortly after rhinoplasty. Digital subtraction angiography demonstrated a pseudoaneurysm arising from the medial orbitofrontal artery. The patient underwent microsurgical trapping and clipping of the pseudoaneurysm with simultaneous repair of an associated cribriform plate defect and cerebrospinal fluid leakage, resulting in complete exclusion of the lesion and an uneventful neurological recovery. Postoperatively, he recovered without neurological deficits and remained clinically stable during follow-up.

Conclusion:

Although extremely uncommon, intracranial pseudoaneurysm should be considered in patients who develop intracerebral hemorrhage after rhinoplasty. Prompt vascular imaging and timely neurosurgical intervention are essential to prevent potentially catastrophic complications and achieve favorable outcomes.

INTRODUCTION

Rhinoplasty is one of the most commonly performed esthetic and reconstructive procedures, generally associated with a high safety profile.[9,12] However, rare but serious complications can occur, including cerebrospinal fluid (CSF) leakage, orbital injury, and vascular damage. Among these, vascular injuries are particularly concerning due to the risk of intracranial hemorrhage and pseudoaneurysm formation.[5,18]

The nasal region is supplied by a complex network of vessels, primarily derived from both the internal and external carotid arterial systems. This dual supply creates a rich anastomotic network that renders the area particularly vulnerable to iatrogenic injury during surgical manipulation.[11] In rhinoplasty, especially during osteotomy or extensive subperiosteal dissection, inadvertent trauma to these vessels may occur. While minor bleeding is a common and expected intraoperative event, significant vascular injury is rare and often underrecognized until postoperative complications arise.[7] The most commonly reported vascular injuries in rhinoplasty involve branches of the external carotid system such as the angular artery, dorsal nasal artery, or branches of the infraorbital artery, manifesting as postoperative hematoma or, in rare instances, pseudoaneurysm formation.[1,18] However, injury to intracranial vessels, particularly branches of the anterior cerebral artery (ACA), is exceptionally uncommon and carries severe consequences.[5]

Pseudoaneurysms result from disruption of the arterial wall with containment of blood by surrounding tissues, rendering them unstable and prone to rupture.[6,8] To our knowledge, pseudoaneurysm of the medial orbitofrontal artery following rhinoplasty has not been previously reported. This case highlights a rare but potentially life-threatening complication and underscores the importance of anatomical awareness and early diagnosis.

CASE PRESENTATION

A 31-year-old male with no significant past medical history underwent elective rhinoplasty with nasal osteotomy at an outside facility. The surgery was performed under general anesthesia using standard techniques. During the osteotomy, the operating surgeon encountered unexpected resistance, raising concern for inadvertent entry into the cranial cavity. The remainder of the procedure was completed uneventfully, and the patient was extubated in stable condition.

Within a few hours postoperatively, the patient developed mild frontal headache and confusion but remained hemodynamically stable. A noncontrast computed tomography (CT) scan was obtained due to the intraoperative event and neurological symptoms. The scan revealed right frontal intracerebral hemorrhage extending from the rectus gyrus to the adjacent medial frontal cortex [Figure 1]. There was minimal mass effect and no evidence of skull base fracture or pneumocephalus at that time.

Figure 1:

Initial noncontrast axial computed tomography scan demonstrating a right frontal intraparenchymal hemorrhage extending from the gyrus rectus to the adjacent medial frontal cortex (arrow), without significant midline shift.

After 10 days, the patient was transferred to our neurosurgical center for further evaluation. On arrival, neurological examination showed the patient to be alert and oriented with no focal deficits. Magnetic resonance imaging confirmed the hemorrhage involving the right frontal lobe and demonstrated surrounding edema and mass effect [Figure 2].

Figure 2:

Axial T2-weighted magnetic resonance imaging showing the right frontal hematoma with surrounding edema and mild mass effect (arrow).

To assess for an underlying vascular lesion, digital subtraction angiography (DSA) was performed. DSA revealed a small aneurysmal dilation arising from the right medial orbitofrontal artery, a branch of the ACA. The aneurysm morphology and location were consistent with an iatrogenic injury secondary to osteotome penetration through the nasal roof [Figures 3 and 4].

Figure 3:

Conventional digital subtraction angiography demonstrating a small pseudoaneurysm arising from the right medial orbitofrontal artery, a distal branch of the anterior cerebral artery (arrow).

Figure 4:

Three-dimensional digital subtraction angiography reconstruction clearly depicting the pseudoaneurysm originating from the right medial orbitofrontal artery (arrow).

Given the risk of rupture and rebleeding, together with persistent postoperative CSF leakage suggesting an anterior skull base injury, an open surgical approach was planned. A right frontal craniotomy was performed to simultaneously treat the vascular lesion and repair the skull base defect. Intraoperatively, a defect involving the cribriform plate was identified. The medial orbitofrontal artery pseudoaneurysm was carefully exposed under the operating microscope and successfully treated by microsurgical trapping and clipping while preserving the surrounding vascular branches. Following vascular reconstruction, the anterior skull base defect was repaired using a fascial patch to achieve watertight closure of the CSF leak. Postoperatively, the patient was extubated without neurological deficit. A follow-up DSA on postoperative day 1 confirmed complete exclusion of the pseudoaneurysm from the cerebral circulation [Figures 5 and 6]. The patient’s recovery was uneventful, and he was discharged home after one week with normal neurological function.

Figure 5:

Postoperative conventional digital subtraction angiography demonstrating complete obliteration of the pseudoaneurysm with preservation of the parent artery and distal cerebral circulation.

Figure 6:

Postoperative three-dimensional digital subtraction angiography confirming complete exclusion of the pseudoaneurysm (arrow) without residual filling. The yellow arrowhead and white symbol were already present in the original image as received from the imaging system and were not added by the authors.

DISCUSSION

Craniofacial pseudoaneurysms are most often iatrogenic, resulting from surgical trauma, or secondary to blunt or penetrating facial injuries. While pseudoaneurysms of extracranial arteries have been documented following rhinoplasty, intracranial pseudoaneurysms following nasal surgery are extraordinarily rare and sparsely reported in the literature.[5]

In reviewing the literature, few cases have described pseudoaneurysm formation involving intracranial arteries following rhinoplasty. The reported cases primarily involve extracranial arteries and typically present as localized facial swelling or delayed bleeding. To our knowledge, pseudoaneurysm of the medial orbitofrontal artery following rhinoplasty has not been previously described. This highlights both the unusual nature of our case and its significance in expanding the current understanding of potential iatrogenic vascular complications in nasal surgery.

Understanding the pathophysiology behind the formation of iatrogenic pseudoaneurysms is crucial. During rhinoplasty, particularly when performing osteotomies or elevating periosteal flaps near the nasofrontal junction, excessive force or deep penetration of instruments can result in bone fractures that extend into the anterior cranial base.[13,16] If the underlying dura mater or cortical vessels are disrupted, arterial blood may extravasate into the surrounding parenchyma or subarachnoid space, initiating pseudoaneurysm development. The clinical manifestation may vary depending on the size and location of the lesion. Some pseudoaneurysms remain asymptomatic for days or weeks before presenting with delayed hemorrhage, while others may rupture acutely, leading to subarachnoid or intracerebral hemorrhage with neurological deterioration.[15]

Anatomically, the orbitofrontal cerebral cortex supplied by the medial and lateral orbitofrontal arteries lies in close proximity to the upper nasal vault and anterior skull base.[4,14] The medial orbitofrontal artery, typically a branch of the A2 segment of the ACA, courses along the medial orbital surface of the frontal lobe and supplies the inferomedial frontal cortex, gyrus rectus, and olfactory sulcus.[2,15,17] Given its anatomical position near the frontal sinus and nasal roof, iatrogenic injury to this vessel during aggressive dorsal hump reduction or osteotomy, though rare, is possible, particularly in cases involving deep or misplaced osteotomes.

Both microsurgical and endovascular techniques have been reported for the treatment of intracranial pseudoaneurysms, and the optimal strategy should be individualized according to aneurysm morphology, vascular anatomy, associated injuries, and institutional expertise. Endovascular treatment offers the advantages of a minimally invasive approach, shorter recovery, and avoidance of craniotomy. However, treatment of pseudoaneurysms arising from very distal ACA branches may be technically demanding because of the small caliber of the parent vessel, fragile aneurysm walls, and the potential need for parent artery sacrifice or embolization.[10,19] In our patient, microsurgical treatment was preferred because it allowed definitive exclusion of the pseudoaneurysm while simultaneously enabling direct repair of the associated anterior skull base defect and persistent CSF leakage. Intraoperatively, a cribriform plate defect was identified and reconstructed using a fascial patch, making microsurgery the most comprehensive treatment strategy.

Although rare, pseudoaneurysm after rhinoplasty can have severe consequences. The majority of reported cases involve branches of the external carotid system, particularly the dorsal nasal artery and angular artery, where patients presented with delayed pulsatile swelling, recurrent epistaxis, or cosmetic deformity days to weeks after surgery.[3,18] These pseudoaneurysms were typically managed successfully with selective endovascular embolization or surgical ligation. In contrast, intracranial pseudoaneurysms arising from the internal carotid or ACA branches present a far more complex diagnostic and therapeutic challenge due to their location, risk of rupture, and potential neurological sequelae.[5]

Prevention of skull base injury during rhinoplasty requires meticulous preoperative planning and careful surgical technique. Preoperative CT evaluation may be considered in selected high-risk patients, such as those undergoing revision rhinoplasty or with a history of facial trauma, to assess anterior skull base anatomy, including Keros classification and anatomic asymmetries. During medial osteotomy, the osteotome should be directed along an oblique trajectory away from the midline, avoiding excessive superior advancement toward the cribriform plate. The use of narrow guarded osteotomes or piezoelectric instruments may further reduce the risk of inadvertent skull base penetration and vascular injury. Surgeons should also avoid excessive mallet force when increased bony resistance is encountered and maintain strict control over osteotome depth throughout the procedure. Adherence to these principles may minimize the risk of skull base violation and rare but potentially catastrophic complications such as intracranial pseudoaneurysm formation.

CONCLUSION

Rhinoplasty, though a routine and generally safe operation, carries potential risks that extend beyond cosmetic or functional outcomes. Vascular complications, especially intracranial pseudoaneurysm formation, represent one of the most serious but underrecognized threats. A deep understanding of nasal and frontonasal vascular anatomy, meticulous surgical technique, and a high index of suspicion in the postoperative period are critical to preventing morbidity and mortality associated with such events. This case report aims to enrich the existing literature by illustrating the mechanisms, diagnostic process, and management approach for a medial orbitofrontal artery pseudoaneurysm following rhinoplasty, thereby reinforcing the need for heightened awareness and early intervention in similar scenarios.

Ethical approval:

Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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