Extracranial carotid arteries aneurysms in children: single-center experiences in 4 patients and review of the literature

Extracranial internal carotid aneurysm treated with a covered stent in an infant

BACKGROUND

Extracranial internal carotid aneurysms consist a rare pathology with an overall incidence less than 1% in the general population, and warrant treatment due to their association with cerebrovascular events and neurological complications. The incidence is even lower in the pediatric population.

CASE REPORT

A 14-month infant presented in our clinic with neck swelling of unknown origin, with subsequent MR imaging revealing an extracranial internal carotid aneurysm. Due to the patient's age and risk of surgical complications, the decision to proceed with endovascular repair with stent placement and complete exclusion of the aneurysm from the circulation was made, after multidisciplinary consultation.

RESULTS

In the pediatric population, pediatric population, endovascular stent placement can be considered at least as a last resort treatment when surgical access harbors significant risks or is impossible.

Infective Native Extracranial Carotid Artery Aneurysms: A Systematic Review

BACKGROUND

Infective native extracranial carotid artery aneurysms are rare, and their management is variable due to a lack of evidence assessing outcomes.

METHODS

We performed a systematic literature review following PRISMA guidelines to identify all reported cases of infective native extracranial carotid artery aneurysms between January 1970 and March 2021.

RESULTS

This study identified 193 infective native aneurysms of the extracranial carotid artery from 154 sources. Patients were predominantly male (71.4%), and age ranged from 6 months to 89 years old. The most common presenting features were a neck mass and fever, but also included hemorrhage, respiratory distress, and neurological symptoms. Most aneurysms were located in the internal carotid artery (47.4%). Staphylococcus (23.3%) was the most commonly identified causative pathogen, followed by Mycobacterium tuberculosis (20.9%). Most appeared to become infected by direct local spread. Treatment strategies involved open surgical methods in 101 cases and an endovascular approach in 41 cases. In 4 cases, a hybrid method involving concurrent endovascular and open surgical management was undertaken. In 5 cases, there was antibiotic treatment alone. In the open surgery-treated group, the complication rate was 20.8% compared to 13.2% in the endovascular group. Mortality rate was 5.6%.

CONCLUSIONS

Our review identified 193 cases of infective native extracranial carotid artery aneurysms. Direct local spread of a staphylococcus infection was the commonest cause. Endovascular management was associated with fewer early complications than open surgical management.

Infectious Pseudoaneurysm of the Internal Carotid Artery in a Child Secondary to Parapharyngeal Abscess

Infectious pseudoaneurysm is a rare condition characterized by arterial wall dilation, usually due to an adjacent infectious focus. We present an 8-year-old male with a 3-day history of progressive, severe headache 2 weeks after treatment for a parapharyngeal abscess. Computed tomography revealed a left internal carotid artery (ICA) pseudoaneurysm inferior to the skull base and a small parapharyngeal abscess inferior to the pseudoaneurysm. The patient was admitted for intravenous antibiotic treatment and underwent transfemoral endovascular coil occlusion of the cervical ICA pseudoaneurysm without complications. We discuss the presentation and management of rare vascular complications of parapharyngeal abscesses involving major arteries of the neck and the role of neurointerventional embolization in these cases.

Endovascular Management of Internal Carotid Artery Pseudoaneurysm Secondary to Pediatric Deep Neck Space Infection: A Case Report and Review of Literature

Pseudoaneurysms of extracranial internal carotid artery (ICA) are rare in children. Main causes include trauma, iatrogenic causes, and neck space infection. Prompt diagnosis and management is vital, in view of life-threatening complications like fatal airway hemorrhage and stroke. Endovascular management has currently become the preferred treatment strategy due to its minimally invasive nature and lower complication rates. We report a rare case of mycotic pseudoaneurysm of extracranial ICA in a 4-year-old child as a complication of neck space infection, which was successfully managed with endovascular parent artery occlusion.

Transarterial embolization with N-butyl 2-cyanoacrylate for the treatment of recurrent secondary post-tonsillectomy hemorrhage

Background

Postoperative hemorrhage is a potential complication of tonsillectomy, and early diagnosis and adequate management are mandatory to prevent hemorrhagic shock. The aim of this study was to assess the safety and efficacy of transcatheter embolization of recurrent post-tonsillectomy hemorrhage by using N-butyl 2-cyanoacrylate.

Results

We performed a retrospective analysis of the medical records, imaging findings, technical details, and clinical outcome of eight patients with delayed post-tonsillectomy hemorrhage who underwent endovascular embolization. All patients were followed up; technical and clinical successes of treatment were evaluated. All patients had arterial pseudoaneurysm as a source of bleeding. The injured artery was facial artery in four patients, lingual artery in three patients, and linguofacial trunk in one patient. All lesions were treated by endovascular embolization using NBCA glue. All patients were successfully embolized with no clinical complications. In one patient with pseudoaneurysm at the ostium of the facial artery, after filling the pseudoaneurysm with glue, inadvertently proximal reflux into the adjacent part of the external carotid artery (ECA) occurred leading to its occlusion with no related immediate or delayed complication.

Conclusion

Endovascular embolization is an effective and almost safe procedure in the management of recurrent post-tonsillectomy bleeding. In such cases, we can use NBCA glue with certain precautions as an effective appropriate embolizing agent.

Case Report: Mycotic common carotid artery pseudoaneurysm in a child. A case report

Extracranial carotid artery aneurysms in children are extremely rare, nevertheless associated with a great potential of thromboembolic episodes and rupture especially those with mycotic origin. The surgical treatment is very challenging, and there is still a controversy concerning revascularisation after the resection of the aneurysm.

In this manuscript, we report the observation of an 8-year-old boy with the medical history of Leukemia who is admitted urgently for a mycotic right common carotid artery aneurysm, occurring after a chemoport infection who was operated on in our cardiovascular surgery department with surgical resection and ligation. It is the second report in the pediatric literature of a mycotic pseudoaneurysm situated in the common carotid artery, but the first documented by medical imagery. Through this case, we highlight that ligation of the infected carotid artery can be a safe and efficient alternative especially in Children.

External carotid artery pseudoaneurysm following upper respiratory infection masquerading as a pharyngeal abscess in an 8-month-old

Pseudoaneurysms are very rare with an incidence of less than 0.1% in the pediatric population. Approximately 30 cases of carotid artery aneurysms in children have been published in the literature, usually affecting children over one year of age. We present one of the youngest cases in the literature; the patient is an 8-month old female with a strep throat infection complicated by pseudoaneurysm development of the external carotid artery. Because of the rarity of these lesions, there is little known regarding the types of clinical presentation and management. They are commonly the result of direct arterial trauma; however, they can also occur secondary to infection, connective tissue disease or arteritis. We are presenting a case with a highly atypical presentation. When present, pseudoaneurysms harbor the potential risk of life-threatening hemorrhage and warrant immediate management. It is important to be aware of cases and the treatment modalities used to guide future diagnosis and planning.

Treatment of large infectious extracranial carotid artery pseudoaneurysms in children: a systematic review of the literature

INTRODUCTION

Extracranial carotid artery pseudoaneurysm is a rare complication of deep neck space infection, and no evidence-based treatment guidelines are available in the literature.

METHOD

To clarify the existing experience of the different treatment strategies, the authors performed a systematic literature search using the PubMed, Ovid EMBASE, and Scopus databases in accordance with PRISMA guidelines to review all reported cases of pediatric patients with infectious carotid pseudoaneurysms larger than 1 cm.

RESULTS

Twenty-six patients with a median age of 4 years (range 6 months-15 years) were identified. Eighteen patients (69.2%) were treated with endovascular methods, 6 patients (23.1%) with surgical methods, 1 patient (3.8%) with a hybrid endovascular/surgical approach, and 1 patient (3.8%) with conservative management. Recurrence of the pseudoaneurysm occurred in 2 cases (7.7%), both of which were successfully retreated. Of the 6 patients (23.1%) who presented with pre-procedure neurologic deficits, 3 patients had complete or near complete resolution of symptoms after intervention and 3 patients had persistent deficits at last follow-up. Four patients (15.4%) experienced new neurologic deficits post-procedure that resolved at last follow-up.

CONCLUSION

The endovascular treatment tends to be the preferred option to treat a large or giant infectious pseudoaneurysm of the carotid artery in the pediatric patient. However, more evidence is necessary to elucidate comparative safety and efficacy profiles of endovascular and surgical management strategies.

A child in shock: carotid blowout syndrome

Paediatricians commonly encounter neck lumps during their routine clinical practice; vascular abnormalities, such as (pseudo)aneurysms, are a rare cause of these. Pseudoaneurysms of the carotid artery in children are usually the result of blunt or penetrating trauma, infection or vasculitis/connective tissue disorders. They can present with a variety of symptoms including neck pain, as a pulsatile neck mass or with compressive symptoms (for example, cranial nerve palsies or dyspnoea). Pseudoaneurysms carry a risk of rupture in which case they are fatal, unless immediate treatment is provided.We report a 17-month-old male child with idiopathic carotid artery blowout syndrome presenting with acute oropharyngeal haemorrhage leading to asystolic cardiac arrest. He was successfully resuscitated and emergency embolisation controlled the bleeding. Despite extensive left hemispheric infarct, he has survived.Carotid artery blowout syndrome needs to be recognised as a potential cause of major haemorrhage in childhood. The purpose of this case report is to remind readers of the differential diagnosis and work-up of a child presenting with a neck lump, to highlight important aspects of the acute management of major haemorrhage and massive blood transfusion in paediatrics, to describe the aetiology, presentation and management of carotid artery pseudoaneurysm in children and to discuss long term rehabilitation in patients with consequent neurological sequelae (including the need for input from multiple specialty teams).

Repair of a true extracranial internal carotid artery aneurysm with transposition surgery in a pediatric patient: A rare case

Objectives

Atherosclerosis is the most common etiologic factor for extracranial carotid artery aneurysm in adults, while in childhood, connective tissue diseases, peritonsillar abscess and infections are the most common. Congenital carotid artery aneurysms are rarely reported in the literature.

Methods

We present a 10-year-old girl with congenital extracranial left internal carotid artery aneurysm and the treatment management.

Results

Computed tomography angiography at six months showed that internal carotid artery segments were normal. There was no obstruction or aneurysm recurrence.

Conclusions

Although extracranial carotid artery aneurysms are rare, they can cause complications such as rupture and thromboembolism with high mortality and morbidity. Therefore, the treatment of extracranial carotid artery aneurysms is recommended.

Extracranial Internal Carotid Aneurysm in a 10-Year-Old Boy Diagnosed via Ultrasound

BACKGROUND

Extracranial carotid aneurysms in children are extremely rare but carry a high mortality and morbidity. For pediatric patients, they are often complications of pharyngeal infections and surgical trauma but can also arise from congenital and inflammatory diseases. They have a wide range of presentation from an asymptomatic mass to a rapidly fatal hemorrhage.

CASE

A 10-year-old boy presented to the emergency department with complaints of a neck mass and residual cough from a recent upper respiratory infection. Ultrasound revealed a carotid aneurysm that was further characterized by magnetic resonance angiography as a 3-cm aneurysm of the internal carotid artery. The patient was taken for surgery where he underwent resection and placement of an interposition graft. The procedure was well tolerated and the boy recovered fully.

DISCUSSION

Carotid aneurysms in children can present with 1 or more of the following: a pulsatile neck mass, hematemesis, epistaxis, neurologic symptoms, and symptoms of airway compression. Although ultrasound is the preferred initial test, the choice of additional imaging for further characterization will depend most on the patient age, hemodynamic stability, airway status, and availability of pediatric anesthesia. Hemodynamic and neurologic status should be monitored closely, and clinicians must also be prepared for a potentially complicated airway. Surgery is indicated for children owing to high risk of neurologic complications.

CONCLUSIONS

Although these lesions are rare, it is crucial that physicians recognize when there is a need for further evaluation so that these children have the most favorable outcomes possible.

Impending Rupture of Internal Carotid Artery Aneurysm Mimicking Peritonsillar Abscess

Extracranial carotid artery aneurysms are rare but important entity. Impending rupture of such aneurysms can lead to catastrophic hemorrhage, airway compromise and may prove fatal. The authors report a case of true aneurysm of cervical internal carotid artery in a four-year-old girl who presented with fever and swelling of neck and oropharynx. High clinical suspicion is required to differentiate aneurysm from peritonsillar and parapharyngeal abscess as incision and drainage can prove fatal. Securing airway beforehand and timely embolization has led to the favorable outcome in the present case.

Hybrid vascular intervention for a giant cervical carotid artery aneurysm in a clopidogrel-hyporesponsive child

Aneurysms of the extracranial internal carotid artery (ICA) in pediatric patients are rare and mostly treated surgically. The authors present the case of a child with a giant extracranial ICA aneurysm presenting with gradual airway compression. A plan was made to explore the aneurysm surgically and straighten the associated carotid artery kinks during the operation to enable further endovascular treatment if primary reconstruction of the carotid artery proved not to be possible. Finally, the aneurysm was successfully treated with staged hybrid intervention, which consisted of surgical correction of parent artery kinks followed by endovascular implantation of stent grafts. The child tolerated the procedure well without adverse events. A craniocervical CT angiogram at 5 months showed patency of the stent construct and relief of airway compression. However, a follow-up CT angiogram at 14 months showed total occlusion of the ipsilateral carotid artery without clinical sequelae and complete cessation of airway compression. The management of this was unique since the patient is the first reported case of clopidogrel hyporesponsiveness in a child undergoing neurovascular intervention with prasugrel monotherapy. Point-of-care testing-based adjustment of prasugrel necessitated education of the patient's family regarding the loss of effect of the prasugrel tablets upon crushing and contact with air.

Saccular pseudoaneurysm of the left common carotid artery in an adolescent: Management with a covered stent

An adolescent patient with a previous history of surgical repair for interrupted aortic arch type B presented with an asymptomatic, saccular pseudoaneurysm of the proximal, common left carotid artery, identified on a follow-up magnetic resonance angiography of the thoracic large vessels. The pseudoaneurysm was successfully excluded with a covered stent. Clinical and radiological follow-up after 2 years was uneventful.

A Rare Cause of Juvenile Stroke: Extracranial Carotid Artery Aneurysm with Venous Complete Reconstruction of the Carotid Bifurcation

Extracranial carotid artery aneurysms (ECAA) are a rare cause of embolic stroke. The underlying etiology is variable, with atherosclerosis being the most common entity in older subjects. Several treatments have been developed over the last 20 years, but the preferred method remains unknown. Notwithstanding the widespread use of endovascular techniques, surgical reconstruction by means of a bifurcated venous bypass graft should be applied in younger patients. In this way, it is possible to avoid major concerns about the development of long-term intrastent restenosis, and also to spare the external carotid artery which represents the main branch for the ipsilateral cerebral and facial perfusion. We propose ECAA resection and interposition of the inverted great saphenous vein to both the internal and external carotid artery by means the use of a tributary, i.e., the Giacomini vein.

Surgical treatment of an extracranial carotid artery aneurysm in a child by an arterial autograft

We report a symptomatic aneurysm of the left common carotid artery (LCCA) in a 6-year-old boy. The patient had been diagnosed and treated 3 years earlier for an isolation of the LCCA with a right-sided aortic arch. At the age of 3 years, the LCCA was reimplanted in the ascending aorta. Three years later, the patient developed a voluminous aneurysm of the LCCA complicated by stroke. An arterial graft was used for the carotid reconstruction with good long-term patency and no aneurysm evolution.

Internal Carotid Artery Pseudoaneurysm and Ischemic Stroke Secondary to Retropharyngeal and Parapharyngeal Abscess

Internal carotid artery pseudoaneurysm is an uncommon complication of retropharyngeal and parapharyngeal abscess in children. Treatment of the pseudoaneurysm has evolved in recent years from surgical ligation to endovascular techniques. Neurologic sequelae most commonly consist of Horner's syndrome with cerebral ischemia being uncommon. The clinical course of a 2-year-old boy with retropharyngeal abscess complicated by internal carotid artery pseudoaneurysm, is described and the literature is reviewed. A conventional angiogram confirmed the presence of a large pseudoaneurysm with no anterograde flow distal to the pseudoaneurysm and substantial collateral flow across the circle of Willis, with filling of the left anterior and middle cerebral arteries via the anterior and posterior communicating arteries. Endovascular occlusion resulted in nonfilling of the left internal carotid artery, pseudoaneurysm, and left internal jugular vein at the base of the skull. Following the procedure, the patient developed transient mild right hemiparesis associated with frontal lobe ischemia.

Pediatric nonaortic arterial aneurysms

OBJECTIVE

Pediatric arterial aneurysms are extremely uncommon. Indications for intervention remain poorly defined and treatments vary. The impetus for this study was to better define the contemporary surgical management of pediatric nonaortic arterial aneurysms.

METHODS

A retrospective analysis was conducted of 41 children with 61 aneurysms who underwent surgical treatment from 1983 to 2015 at the University of Michigan. Arteries affected included: renal (n = 26), femoral (n = 7), iliac (n = 7), superior mesenteric (n = 4), brachial (n = 3), carotid (n = 3), popliteal (n = 3), axillary (n = 2), celiac (n = 2), ulnar (n = 2), common hepatic (n = 1), and temporal (n = 1). Intracranial aneurysms and aortic aneurysms treated during the same time period were not included in this study. Primary outcomes analyzed were postoperative complications, mortality, and freedom from reintervention.

RESULTS

The study included 27 boys and 14 girls, with a median age of 9.8 years (range, 2 months-18 years) and a weight of 31.0 kg (range, 3.8-71 kg). Multiple aneurysms existed in 14 children. Obvious factors that contributed to aneurysmal formation included: proximal juxta-aneurysmal stenoses (n = 14), trauma (n = 12), Kawasaki disease (n = 4), Ehlers-Danlos type IV syndrome (n = 1), and infection (n = 1). Preoperative diagnoses were established using arteriography (n = 23), magnetic resonance angiography (n = 6), computed tomographic arteriography (n = 5), or ultrasonography (n = 7), and confirmed during surgery. Indications for surgery included risk of expansion and rupture, potential thrombosis or embolization of aneurysmal thrombus, local soft tissue and nerve compression, and secondary hypertension in the case of renal artery aneurysms. Primary surgical techniques included: aneurysm resection with reanastomsis, reimplantation, or angioplastic closure (n = 16), interposition (n = 10) or bypass grafts (n = 2), ligation (n = 9), plication (n = 8), endovascular occlusion (n = 3), and nephrectomy (n = 4) in cases of unreconstructable renal aneurysmal disease. Later secondary operations were required to treat stenoses at the site of the original aneurysm repairs (n = 2) and new aneurysmal development (n = 1). Postoperative follow-up averaged 47 months (range, 1-349 months). No major perioperative morbidity and no mortality was encountered in this experience.

CONCLUSIONS

Pediatric arterial aneurysms represent a complex disease that affects multiple vascular territories. Results of the current series suggest that individualized surgical treatment, ranging from simple ligations to major arterial reconstructions, was durable and can be undertaken with minimal risk.

Extracranial internal carotid artery pseudoaneurysm in a two-year-old child: case report

BACKGROUND

Extracranial internal carotid artery pseudoaneurysm is very rare in children.

METHOD

This paper discusses the case of a boy, aged two years and six months, who presented with an enlarging neck mass and unilateral bloody otorrhoea. Special investigations revealed an extracranial internal carotid artery pseudoaneurysm.

RESULTS

The patient made a full recovery after endovascular occlusion of the internal carotid artery and pseudoaneurysm using coils. At six months' follow up, the internal carotid artery and pseudoaneurysm remained excluded from the circulation. The patient did not display any neurological deficits during hospital stay or follow up.

CONCLUSION

This paper reports on one of the youngest patients documented to date who presented with an internal carotid artery pseudoaneurysm, possibly secondary to ear infection. Although rare, this condition should be excluded in children presenting with a mass of the neck or pharynx because of the dire consequences if left undiagnosed and untreated.

Pseudoaneurysm of the Common Carotid Artery in an Infant due to Swallowed Fish Bone

Carotid artery pseudoaneurysm is a rare condition, particularly in the paediatric population. Only about 30 cases of carotid artery aneurysms in infants have been published until now. This paper reports the case of a giant pseudoaneurysm of the left common carotid artery due to swallowed fish bone by an 8-year-old boy. This pseudoaneurysm was 5.5 cm transverse-diameter and resulted in severe respiratory distress. It was treated by resection and end-to-end anastomosis with satisfactory outcome after one-year follow-up. To the best of our knowledge, this is the largest carotid artery pseudoaneurysm ever described in children.

Carotid artery pseudoaneurysm: A rare complication following tonsillectomy

Tonsillectomy is one of the most common surgical procedures performed in children. The most frequent complications are dehydration and bleeding. We present the case of a 6 year old child who developed an internal carotid artery pseudoaneurysm following elective tonsillectomy, necessitating urgent coil embolization and stenting. This is the first reported case in the pediatric population of a vascular injury that manifested in a delayed fashion (6 months) after routine tonsillectomy, and is also one of the youngest reported cases. It is imperative for the otolaryngologist to be aware of this rare complication.

True extracranial carotid artery aneurysm in a child

Isolated true aneurysm of the extracranial carotid artery is a rare entity in the pediatric population, with nine reported cases found in the literature. Contrary to adult carotid aneurysms, which are often due to atherosclerotic disease, pediatric aneurysms are more likely to be the result of congenital malformations, connective tissue diseases, or systemic inflammatory conditions. We present the case of a 10-year-old boy with an isolated true aneurysm of the internal carotid artery and a review of the literature.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Internal carotid artery stenosis as the sequela of a pseudoaneurysm after methicillin-resistant Staphylococcus aureus infection

Pseudoaneurysm of the internal carotid artery is an extremely uncommon complication of pediatric deep neck space infections in the postantibiotic era, and poses a diagnostic challenge to clinicians. Early recognition and aggressive management are essential to prevent mortality and serious morbidity. We describe a pseudoaneurysm of the left internal carotid artery after a retropharyngeal abscess in an infant. The retropharyngeal abscess required surgical drainage, and the pseudoaneurysm was managed conservatively with antibiotic therapy. The patient developed 50% stenosis of the left internal carotid artery after recovery. Limited data are available about long-term outcomes of pseudoaneurysms of the internal carotid artery. During 7-year follow-up, she demonstrated no neurologic sequelae and normal development. Despite the left internal carotid artery stenosis, blood supply to the left cerebral hemisphere is well maintained through the circle of Willis. We highlight the importance of early recognition and aggressive management to avoid serious outcomes.

Giant extracranial aneurysm of the internal carotid artery in neurofibromatosis type 1. A case report and review of the literature

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by cutaneous pigmentations, neurofibromas, Lisch nodules and neuroectodermal tumors. Supra-aortic vessel aneurysms may affect patients with NF-1 and can be associated with rupture, ischemic complications and compression symptoms. We describe a 48-year-old woman with NF-1 and an extracranial 3×5 cm right internal carotid artery aneurysm. After balloon test occlusion the patient was treated with parent artery sacrifice which led to significant shrinkage on follow-up MR and reduction of compression symptoms. The literature concerning internal carotid artery aneurysms associated with NF-1 is reviewed evaluating the possible therapeutic options.

Internal carotid artery pseudoaneurysm with life-threatening epistaxis as a complication of deep neck space infection

Pseudoaneurysm of the cervical internal carotid artery is a very rare, potentially fatal complication of a neck space infection in children associated with high mortality and morbidity. A 3-year-old boy presented with spontaneous massive epistaxis 45 days after a deep neck space infection caused by a peritonsillar abscess. During nasopharyngeal packing, he evolved with cardiac arrest. Intra-arterial angiography was then performed that revealed a large pseudoaneurysm. Endovascular treatment using detachable balloons achieved complete exclusion of the pseudoaneurysm. The child made an uneventful recovery and was discharged with mild left hemiparesis and no deficit of sensory or cognitive functions. Pseudoaneurysms of the internal carotid artery after a deep neck space infection can be associated with delayed and potentially fatal massive epistaxis. Furthermore, a regional (ie, extranasal) blood vessel should be promptly investigated when there are signs of hypovolemic shock. A high level of suspicion and definitive treatment are essential for successful management of these patients.

Surgical repair of a giant pseudoaneurysm of the right common carotid artery following a gunshot

Common carotid pseudoaneurysms are very rare. The authors report a case of a 18-year-old patient with 11 cm large posttraumatic pseudoaneurysm of the right common carotid artery caused by a gunshot in the neck. The patient also had a right hemiplegia, secondary to the left sylvian artery stroke and aphasia. A surgical repair was undertaken with an approach including a total sternotomy. The aneurysm was excluded and a saphenous vein patch was used to repair the 2-cm defect on the arterial wall. The postoperative period was uneventful. This is probably the largest carotid artery aneurysm ever described. The potential hazards of an aneurysm of the common carotid artery indicate that surgical treatment is warranted particularly in a patient with a past history of controlateral stroke.

Use of multi-detector computed tomographic angiography in the diagnosis of a parapharyngeal aneurysm in a 6-week-old foal

Multidetector-row computed tomographic contrast angiography (MDCTA) is routinely employed to investigate vascular masses in human patients but, to date, the use of this technique to investigate an aneurysmal mass has not been reported in an equine case. The potential of MDCTA to investigate a right-sided parapharyngeal mass in a 6-week-old Thoroughbred foal was therefore investigated. A 4-slice helical computed tomography scanner was used on a superficial, firm, ovoid mass yielding arterial blood on fine needle aspiration. MDCTA enabled identification of the vessels involved thus assisting in forming a diagnosis based on the morphology of the lesion and aided surgical planning. Histology confirmed the presence of mural thrombus and calcification within the smooth muscle wall consistent with a true aneurysm. MDCTA provided additional information to conventional imaging in this case of vascular masses of the head and neck. The technique therefore has the potential to improve diagnosis and assist in the management of such lesions.

Post-tonsillectomy pseudoaneurysm: an underestimated entity?

Objective:

To identify patients undergoing arteriography to verify vascular complications of tonsillectomy, with an emphasis on pseudoaneurysm.

Patients and methods:

We undertook a retrospective analysis of the case records of 8837 patients who had undergone tonsillectomy between 1988 and 2004 at our institution, together with a review of expert reports written for professional boards and civil courts as well as personal experiences or communication. We also conducted a literature review using the PubMed database.

Results:

We identified seven cases with vascular abnormalities. In addition, we identified three cases of pseudoaneurysm formation, involving two children and one adult patient, with bleeding 21, 36 and 58 days after tonsillectomy. Successful management included embolisation (two patients) and revision surgery (one patient).

Conclusion:

Post-tonsillectomy pseudoaneurysm formation is extremely rare and unrestricted by age. Correct diagnosis depends largely on a high index of clinical suspicion. Delayed and repeated episodes of gushing haemorrhage with spontaneous cessation appear to be a significant clinical marker. Immediate arteriography, with simultaneous embolisation, is highly recommended. The lingual artery is the most commonly involved vessel.