Management of Carotid Blowout from Radiation Necrosis

Comprehensive Treatment Strategy for Internal Carotid Artery Blowout Syndrome Caused by Nasopharyngeal Carcinoma

OBJECTIVE

To evaluate a treatment strategy for internal carotid artery blowout syndrome caused by nasopharyngeal carcinoma.

STUDY DESIGN

A retrospective analysis of a case series was performed.

SETTING

Carotid blowout syndrome is a catastrophic complication caused by malignant tumor of the skull base.

METHODS

A retrospective analysis based on 69 patients with internal carotid artery blowout syndrome admitted to our center between April 2018 and January 2020 was performed. The patients were divided into 2 groups: an EBBA (internal carotid artery embolization + bypass based on American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology [ASITN/SIR]) group and an embolization/stent group. The follow-up time was 6 to 9 months.

RESULTS

In the EBBA group, 41 patients (41/49, 83.7%) survived. Forty patients had a satisfactory quality of life after 3 months. No death occurred within 3 months. Nonoperative death occurred in 8 cases (8/49, 16.3%). The rate of mortality and disability was 18.4% (9/49). In the embolization/stent group, 16 patients (16/20, 80%) survived. Nonoperative death occurred in 4 cases (4/20, 20%), 3 of which occurred within 1 to 3 months. Four cases reported Modified Rankin Scale ≥2 after 3 months. The rate of mortality and disability was 40% (8/20).

CONCLUSION

A comprehensive revascularization strategy for internal carotid artery (ICA) embolization and intracranial and extracranial bypass grafting based on ASITN/SIR score for ICA blowout syndrome patients not only can prolong the patient survival but also greatly improve the survival probability and quality of life as well as reduce their rate of mortality or disability.

Carotid blowout syndrome after reirradiation for head and neck malignancies: a comprehensive systematic review for a pragmatic multidisciplinary approach

AIM

To provide a literature review on risk factors and strategies to prevent acute carotid blowout (CBO) syndrome in patients who underwent reirradiation (reRT) for recurrent head and neck (HN) malignancies.

PATIENTS AND METHODS

Inclusion criteria were: 1) CBO following reRT in the HN region, 2) description on patient-, tumor- or treatment-related risk factors, 3) clinical or radiological signs of threatened or impending CBO, and 4) CBO prevention strategies.

RESULTS

Thirty-five studies were selected for the analysis from five hundred seventy-seven records. Results provided indications on clinical, radiological and dosimetric parameters possibly associated with higher risk of CBO. Endovascular procedures (artery occlusion and stenting) to prevent acute massive hemorrhage in high risk patients were discussed.

CONCLUSION

Literature data are still scarce with a low level of evidence. Nevertheless, the present work provides a comprehensive review useful for clinicians as a multidisciplinary pragmatic tool in their clinical practice.

Stent grafts in patients with carotid blowout syndrome: Outcome and antiplatelet therapy in preventive versus emergency cases

BACKGROUND

Carotid blowout syndrome due to tumor infiltration, fistulas, and therapy-related necrosis can occur as late as years after the treatment. Reporting our experiences with preventive and acute treatment with stent grafts and discussing different ways of antiplatelet therapy.

METHODS

We reviewed all patients between 2010 and 2016 who underwent stent graft placement and analyzed outcome, complications, and antiplatelet regime.

RESULTS

Seventeen patients were treated in 24 sessions (n = 7 threatened, n = 5 imminent, and n = 12 acute bleeding). The antiplatelet regime covered the entire range from aspirin only to loading doses of aspirin/clopidogrel, perioperative heparin, and aspirin/clopidogrel for 12 months followed by lifelong aspirin. Rare complications were not associated with the preprocedural or periprocedural but were associated with the postprocedural antiplatelet regime.

CONCLUSION

Most complications of stent graft implantations due to a carotid blowout syndrome occur postprocedurally: rare thrombotic events are linked to not taking a medication and frequent rebleedings may be reduced by an earlier reduction of dual-antiplatelet to mono-antiplatelet therapy.