Management Challenges of Internal Carotid Artery Pseudoaneurysm in Skull Base Osteomyelitis

Abstract Skull base osteomyelitis is a potentially life-threatening infection typically seen in elderly diabetic or immunocompromised patients. Internal carotid artery pseudoaneurysm caused by skull base osteomyelitis is a very rare complication. We present here three such instances to share our clinical experience and insights gained in the management of these cases. A retrospective clinical audit of 142 skull base osteomyelitis patients (January 2010–May 2023) revealed three cases complicated by pseudoaneurysm at the cervicopetrous junction, with Pseudomonas being the primary causative organism. Two patients underwent successful endovascular coiling and survived after prolonged antipseudomonal therapy. A literature review of 12 similar cases also showed Pseudomonas as the dominant pathogen, whereas 1 case each was caused by tuberculosis and fungal infection. Most patients received antimicrobial therapy for more than 3 months. Follow-up data were unavailable for seven patients; among the remaining cases, all survived except one. Internal carotid artery mycotic pseudoaneurysm is a rare yet potentially devastating complication of skull base osteomyelitis. Timely diagnosis and aggressive treatment are crucial to prevent catastrophic outcomes. Endovascular therapy has emerged as the primary modality for the management of these aneurysms. In the absence of surgical debridement for treatment of skull base osteomyelitis, prolonged antimicrobial therapy (at least 3 months) is essential.