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Repeated nosebleeds…discovered left internal carotid aneurysm!!!

Recently, City Children’s Hospital, received a case of 13-year-old LSV child, female, weighing 40 kg, living in Binh Tan district, Ho Chi Minh City, in a state of shortness of breath, cyanosis, cold hands and feet, face and feet. green hand. Taking the recorded medical history, the children often stopped bleeding on their own, were admitted to the local hospital twice, examined and treated for rhinosinusitis, their condition improved and were discharged. This time, the child had a lot of nosebleeds, vomiting, and fatigue, so the family took the child to the City Children’s Hospital.

Here, the child is cyanotic, has difficulty breathing, light pulse is difficult to catch, blood pressure is 70/50mmHg, cold extremities are purple, and the skin is pale. Doctors diagnosed hemorrhagic shock due to massive nosebleeds, differentiated from gastrointestinal bleeding. An urgent Hct (RBC) test to 16% (normal in this child Hct 38-45%) showed hemophilia, an arterial blood gas test showed severe metabolic acidosis, and Blood lactate index increased by 9.5mmol/L (normal <2mmol/L), indicating very severe tissue hypoperfusion, coagulation function tests, and normal platelet count. Children were treated with respiratory support, anti-shock fluids, transfused red blood cells, vitamin K1, bicarbonate compensation, nasogastric tube placement, consultation with an otolaryngologist to learn how to insert a nose meche to stop bleeding. The child's condition improved, hemodynamically stable Hct reached 36%-38%, the nasal mechee was removed after 5 days, no further bleeding was observed.

However, 2 days later, the child continued to have nosebleeds, a large amount caused shock, blood loss, respiratory failure, and was given by doctors in respiratory and circulatory resuscitation: intubation to help breathing, blood transfusion to prevent shock, Infusion of fresh frozen plasma, intravenous calcium supplementation, the child’s condition improved, he was consulted by a neurosurgeon, and brain angiography was performed using digital angiography (Digital Subtraction Angiography – DSA).

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The results showed that the child had an aneurysm of the left internal carotid artery near the cavernous sinus next to the sinus area, size 9.5 × 8.3 × 7.3 mm, neck (peduncle) # 4.4 mm, causing bleeding when ruptured. nose blood. The doctors threaded a specialized wire to put the coils (using 8 coils) into the correct aneurysm to seal the blockage. After the intervention, the child’s condition improved gradually, was weaned from the ventilator, breathed air, hemodynamically stable, was alert and was discharged 3 days later and was scheduled for periodic re-examination.

This is a rare case of aneurysms in children, which can be caused by trauma, vasculitis, bacterial infection, fungal infection, etc., causing micro-damage of the arterial wall, etc., in addition, in adults who smoke. , drinking a lot of alcohol, high blood pressure or drug addicts… are at risk of aneurysms.

Through this case, we warn parents when seeing their child’s nose bleed, immediately give first aid to the child leaning forward, leaning back, pressing with index finger or thumb. on the side of the nose bleeding, press both sides if bleeding on both sides, instruct the child to breathe through the mouth. Then, take the child to the hospital to be examined by a doctor and find the cause of the nosebleed to have an appropriate treatment. fit.

Digital angiography with background erasure shows a left internal carotid aneurysm.
Digital angiography with background erasure shows a left internal carotid aneurysm.
13-year-old LSV child, female, hemorrhagic shock due to severe nosebleed, received intensive respiratory resuscitation weeks before the child was intervened to block the aneurysm aneurysm
13-year-old LSV child, female, hemorrhagic shock due to severe nosebleed, received intensive respiratory resuscitation weeks before the child was intervened to block the aneurysm aneurysm
After occlusion of left internal carotid artery aneurysm, the child gradually recovered, stopped bleeding from the nose, weaned from the ventilator, regained consciousness and was discharged from the hospital, and was scheduled for regular check-ups.
After occlusion of left internal carotid artery aneurysm, the child gradually recovered, stopped bleeding from the nose, weaned from the ventilator, regained consciousness and was discharged from the hospital, and was scheduled for regular check-ups.

Doctor of K2 Nguyen Minh Tien
City Children’s Hospital

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