Ruptured infectious pseudoaneurysm of the high cervical (parapharyngeal) internal carotid artery (ICA) complicating skull base osteomyelitis (SBO) is a life-threatening emergency, especially when active exsanguination makes immediate transfer unsafe. Although parent artery-preserving reconstruction is increasingly used, uncontrolled infection, massive transfusion requirements, and contraindications to dual antiplatelet therapy (DAPT) may preclude complex reconstruction. We describe a safety-first, transfer-constrained decision-support workflow for damage-control neurovascular care, integrating a decision matrix with a stepwise emergency parent artery occlusion (PAO) protocol. In our illustrative case, progressive lower cranial neuropathy (CN IX-XII) prompted urgent vascular imaging, which identified a left high cervical (parapharyngeal) ICA pseudoaneurysm adjacent to the carotid canal. Catastrophic epistaxis was controlled on-site within 58 minutes using PAO after rapid angiographic collateral verification, with only punctate ischaemic lesions and functional recovery (modified Rankin Scale score, 1). Using this illustrative case, we present a structured model for explicit, time-critical reasoning when biology and logistics favour deconstruction over reconstruction. Serial contrast-enhanced MRI at 3.5 and 8.6 months demonstrated continued improvement in skull-base inflammatory changes without pseudoaneurysm recurrence.
Yokouchi et al. (2026) studied this question.