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Carotid pseudoaneurysm of the neck.

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A 51-year-old man had worsening sore throat, hoarseness, and dysphagia for more than 2 weeks despite being on antibiotics 1 week prior to admission. At the time of presentation, he exhibited left-sided neck swelling, vision impairment in the left eye, headaches, and pain in the left side of the face. He denied any history of trauma.

On physical examination, an enlarged left-sided neck mass was observed, with erythema extending into the parapharyngeal space. Lab values were significant for a white blood cell count of 16.9 x [10.sup.3]/ml with neutrophil predominance (87%).

After diagnostic imaging (figure), the patient underwent surgical exploration of the left carotid space to repair a pseudoaneurysm, as demonstrated on imaging. The patient experienced no significant complication or neurologic deficit after surgery. He was placed on antibiotics and discharged 4 days after admission in stable condition.

Pseudoaneurysms, or false aneurysms, are formed by the leakage of blood from an artery into the surrounding tissues. The opening between this bloodfilled space, or hematoma, and its originating artery remains patent. Pseudoaneurysms differ from true aneurysms

in that true aneurysms are an abnormal dilatation or ballooning of the artery, containing all three normal layers of the vessel wall (endothelium, media, and adventitia). (1) Pseudoaneurysms can occur on any artery in the body, including the aorta, femoral artery, carotid, and intracranial arteries.

Carotid pseudoaneurysms in the neck are of particular concern as they arise from the carotid arteries and impair blood flow by compressing adjacent structures within the neck. Complications can be significant if they are not treated promptly. Carotid pseudoaneurysms most commonly occur after trauma to the carotid space, such as injuries sustained in motor vehicle accidents, gunshot wounds, iatrogenic procedures, or injections into the neck, including the injection of illicit drugs. (1-3) Rarely, they also can arise from inflammatory or infectious processes in neck, as occurred in our patient. (4)

Carotid pseudoaneurysms can be diagnosed by computed tomography (CT) and/or ultrasound imaging as a blood collection/hematoma arising from the carotid vessel with significant mass effect compromising the adjacent neck structures, including airways. (1) They have been treated in the past with open surgical repair, but endovascular procedures--such as percutaneous angioplasty, stenting, and coil embolization--have gained favor as they are less invasive. (5,6)

Clinicians must maintain a high index of suspicion for a carotid pseudoaneurysm forming in a rapidly enlarging neck mass in individuals with the abovementioned risks.

References

(1.) Magge D, Farber A, Vladimir F, et al. Diagnosis and management of traumatic pseudoaneurysm of the carotid artery: Case report and review of the literature. Vascular 2008;16(6):350-5.

(2.) Benedict WJ, Prabhu V, Viola M, Biller J. Carotid artery pseudoaneurysm resulting from an injury to the neck by a fouled baseball. J Neurol Sci 2007;256(1-2):94-9.

(3.) Abrames EL, Chen SR, Jones W, Folio L. Radiology corner. Traumatic carotid pseudoaneurysm post gun shot wound to the head/ neck. Mil Med 2008;173(5):xv-xvi.

(4.) Wales L, Kruger AJ, Jenkins JS, et al. Mycotic carotid pseudoaneurysm: Staged endovascular and surgical repair. Eur J Vasc Endovasc Surg 2010;39(1):23-5.

(5.) Chaer RA, Derubertis B, Kent KC, McKinsey ]E Endovascular treatment of traumatic carotid pseudoaneurysm with stenting and coil embolization. Ann Vasc Surg 2008;22(4):564-7.

(6.) DuBose J, Recinos G, Teixeira PG, et al. Endovascular stenting for the treatment of traumatic internal carotid injuries: Expanding experience. J Trauma 2008;65(6):1561-6.

Edward C.F. Lam, MS4; Enrique Palacios, MD, FACR; Harold Neitzschman, MD, FACR, FACNM, FAAP

From the John A. Burns School of Medicine, University of Hawaii, Honolulu (Mr. Lam); and the Department of Radiology, Tulane University Hospital and Clinics, New Orleans (Dr. Palacios and Dr. Neitzschman).
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Title Annotation:IMAGING CLINIC
Author:Lam, Edward C.F.; Palacios, Enrique; Neitzschman, Harold
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Date:Nov 1, 2011
Words:622
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