• aneurysm
• epistaxis
• nasal

A 90 year old woman was admitted to our accident and emergency department with spontaneous brisk epistaxis. On arrival she was profoundly hypotensive and unresponsive. Her airway and breathing were managed according to Advanced Life Support protocol. Volume resuscitation was started and intranasal packs used in an attempt to curtail the epistaxis. Unfortunately these measures were unsuccessful and the patient died shortly after presentation.

Postmortem examination revealed an 8×6×3 cm internal carotid artery (ICA) aneurysm in the base of the skull extending into the ipsilateral anterior and middle fossae and crossing the pituitary fossa to reach the contralateral anterior fossa. There was patchy erosion of the contralateral basal skull bones and a large defect communicating with the nasal space. The cause of death was recorded as epistaxis secondary to an ICA aneurysm.

Epistaxis is a common symptom that can usually be managed conservatively by means of anterior and posterior gauze packing.¹ It is rarely caused by ICA aneurysm.² Attempted management of epistaxis secondary to ruptured ICA aneurysm using standard measures is often futile³ and mortality is high.⁴ For this reason other techniques have been devised for use in the acute situation, including internal carotid artery ligation at the neck⁵ and endovascular methods such as balloon embolisation,⁶ stent deployment,⁷ and the use of microcoils.⁶

This letter is intended to raise awareness of a less common but dramatic cause of epistaxis that is commonly fatal if undiagnosed.