Occult ascending pharyngeal artery pseudoaneurysm masked by CTA artifact after penetrating facial trauma: a case report

Penetrating facial trauma can result in vascular abnormalities that are difficult to identify on initial imaging due to artifact from retained fragments. External carotid artery pseudoaneurysms are uncommon but may carry significant morbidity if not promptly recognized. A 34-year-old female presented after a gunshot wound to the left face. Initial computed tomography angiography (CTA) demonstrated left vertebral artery V3 dissection, severe left internal carotid artery stenosis, and a comminuted mandibular fracture with retained ballistic fragments causing substantial streak artifact. Due to persistent concern for vascular injury, craniocervical angiography was performed and revealed distal left vertebral artery occlusion, left internal carotid artery dissection, and a pseudoaneurysm arising from the ascending pharyngeal branch of the external carotid artery. Coil embolization was successfully performed. Occult vascular injury should remain a concern following penetrating facial trauma despite nondiagnostic CTA findings. Early angiographic evaluation may influence management and operative planning.