Case summary

A 71-year-old woman with hypertension on aspirin presented with recurrent syncope, intermittent epistaxis, melena, and visual disturbances. She was found to have severe anemia (hemoglobin 63 g/L), hypotension, and profound bradycardia requiring temporary pacing. A gastrointestinal source was initially suspected; however, upper endoscopy was negative, creating diagnostic uncertainty.

Brain CT revealed a left posterior cerebral artery infarct, correlating with her visual symptoms. Following clinical deterioration and a massive episode of epistaxis, computed tomography angiography (CTA) of the head and neck was performed, demonstrating a 7 mm paraophthalmic internal carotid artery (ICA) aneurysm projecting into the sphenoid sinus, consistent with rupture.

Her bradycardia was attributed to the trigeminocardiac reflex, likely triggered by nasal packing, further complicating the presentation. Diagnosis was confirmed with cerebral angiography, and the patient underwent successful endovascular coiling with complete aneurysm occlusion.

She stabilized rapidly post-procedure, with resolution of bleeding and no further neurologic decline. This case highlights a rare but important presentation of a ruptured ICA aneurysm mimicking gastrointestinal bleeding and underscores the need for early vascular imaging in atypical cases.

Why this case matters

Epistaxis may reflect intracranial vascular rupture
Melena from swallowed blood can mimic GI bleeding
Trigeminocardiac reflex may cause bradycardia after nasal packing
Early CTA is essential in unexplained anemia with negative endoscopy

Question

Which finding most strongly suggested a non-gastrointestinal source of bleeding?

A. Melena
B. Severe anemia
C. Negative upper endoscopy
D. Hypotension

Correct answer

C. Negative upper endoscopy

Explanation

A negative endoscopy despite melena and anemia pointed to a non-GI source—ultimately leading to diagnosis of a ruptured ICA aneurysm.

Clinical Take-Home Message

In patients presenting with unexplained anemia, melena, and epistaxis—especially when gastrointestinal evaluation is negative—clinicians should consider a vascular etiology such as a ruptured internal carotid artery aneurysm and proceed with early CTA to prevent delayed diagnosis and life-threatening hemorrhage.

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