Endovascular Treatment for Ruptured Internal Carotid Artery Pseudoaneurysms Secondary to Radiotherapy for Nasopharyngeal Carcinoma: A Retrospective Analysis

AIMS: We aimed to evaluate the safety and efficacy of endovascular intervention in treating ruptured internal carotid artery (ICA) pseudoaneurysms secondary to radiotherapy for nasopharyngeal carcinoma (NPC). METHODS: We retrospectively analyzed consecutive patients with NPC and angiographically confirmed ruptured ICA pseudoaneurysms who underwent endovascular treatment at Nanjing First Hospital, Nanjing Medical University, between September 2016 and September 2023. After CTA or emergency DSA, the bleeding site and collateral circulation were assessed. Balloon test occlusion (BTO) was performed selectively when parent artery occlusion (PAO) was considered feasible. Treatment was individualized using covered stent implantation, coil embolization combined with a liquid embolic agent, or PAO. Outcomes included final angiographic hemostasis, recurrent bleeding, complications (analyzed as events when patients had more than one event), and the modified Rankin Scale (mRS) at last follow-up. RESULTS: Thirty-two patients were analyzed: 15 underwent coil embolization combined with a liquid embolic agent, 12 covered stent implantation, and 5 PAO. BTO was performed in 8 patients (25.0%): 5 tolerated BTO and underwent PAO, whereas 3 had inadequate collateral reserve and received reconstructive treatment. Final angiographic hemostasis was achieved in all 32 patients (100%; 95% exact CI 89.1-100%). At last follow-up, 28 patients (87.5%; 95% CI 71.0%-96.5%) had mRS 0-1. Six complication events were recorded across 32 procedures (18.8 events per 100 procedures): 4 recurrent bleeding events and 2 transient limb weakness events, graded as Medical Research Council muscle-power grade 3. One patient contributed both recurrent bleeding and transient weakness; therefore event rates should not be interpreted as unique-patient incidence. No severe complications were observed. CONCLUSION: Endovascular treatment achieved immediate hemostasis in this small, retrospective series of ruptured radiation-related ICA pseudoaneurysms. Treatment should be individualized according to collateral reserve, vascular anatomy, and the feasibility of BTO. Covered stents and coil-based reconstruction can preserve the parent artery but require close surveillance for endoleak, residual pseudoaneurysm, and new lesions. PAO may be considered only when collateral circulation is adequate; the zero-event estimate in five patients has a wide confidence interval. These exploratory findings require confirmation in larger prospective studies.