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

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.

Paediatric Deep Neck Infection—The Risk of Needing Intensive Care

Deep neck infections are potentially dangerous complications of upper respiratory tract or odontogenic infections. The pathophysiology, clinical presentation, and potential spreading depend on the complex anatomy of the neck fascia. These infections can lead to severe pathological conditions, such as mediastinitis, sepsis, and especially airway impairment with difficult management. Because of the risk of life-threatening emergency situations and the possible impacts on the overall health status of affected children, their early recognition is of utmost importance. Torticollis, drooling, and stridor are the most common signs of advancing disease. Children presenting with these symptoms should be admitted to the paediatric intensive care unit for vital function monitoring, where the airway could be readily secured if function is compromised.

Complications of peritonsillar abscess

Background

The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications.

Methods

Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited.

Results

Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%).

Conclusion

Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients  > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.

Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy

BACKGROUND

There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series.

OBJECTIVE

To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms.

METHODS

This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up.

RESULTS

A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients.

CONCLUSION

The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.

Rupture of Internal carotid artery pseudoaneurysm in the sphenoid sinus as a complication of deep neck space infection

BACKGROUND

Pseudoaneurysm of the internal carotid artery (ICA) is a very rare but potentially fatal complication of deep neck space infection.

METHODS

This paper describes a very rare case of an ICA pseudoaneurysm rupture in the sphenoid sinus caused by a deep neck abscess.

RESULTS

A 62-year-old male with a deep neck space infection underwent surgical drainage. On the postoperative 21st day, however, he suddenly had massive epistaxis. A transnasal endoscopic examination found massive bleeding out of the sphenoid sinus. Immediate intra-arterial angiography revealed two pseudoaneurysms of the left ICA at the cavernous segment (C4) and the clinoid segment (C5), which were embolized with coils. The patient made an uneventful recovery after the embolization.

CONCLUSION

We found no reports in the literature that pseudoaneurysms associated with a deep neck infection rupture in the sphenoid sinus. Prompt treatment along with accurate diagnosis is essential for successful management of such cases. J. Med. Invest. 66 : 188-189, February, 2019.

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.

Management of Arterial Pseudoaneurysms of the Neck in a Pediatric Population: An Endovascular Case Series and Review of Literature

BACKGROUND

Arterial pseudoaneurysms of the neck are rarely reported in the pediatric population and no dedicated large series are available. Trauma and infection are the most common causes for these aneurysms, with congenital and collagen vascular disorders being the less common causes. These lesions can be life threatening, especially when they present with bleeding or airway compromise.

METHODS

We searched our radiology information system for all cases of pediatric neck aneurysm presented between June 2015 and May 2018. These cases were analyzed for clinicoepidemiologic variables, clinical presentation, imaging findings, management, and follow-up.

RESULTS

Six children were included in the study (male/female ratio, 5:1), with a mean age of 7.8 years (range, 2.5-15 years). Four presented acutely with either bleeding or rapidly enlarging neck swelling, whereas 2 presented with slowly increasing pulsatile swelling. One had a traumatic cause, 2 had infections, and 1 had infective cervical lymphadenitis complicated by iatrogenic injury whereas no definite causative mechanisms could be accounted for in 2 patients. Two of the children were managed by trapping of the aneurysm and 2 only by proximal parent vessel occlusion. The other 2 children were treated with stent graft deployment across the aneurysm neck to reconstruct the parent vessel. All the patients were doing well during the follow-up period (mean, 14.8 months).

CONCLUSIONS

Endovascular means of treatment for pediatric neck aneurysms is relatively simple and safe. Although parent vessel sacrifice is the gold-standard management, vessel-preserving strategies can be tried in select cases with favorable anatomy.

Rare Post-Tonsillectomy Internal Carotid Artery Pseudoaneurysm: Management by Parent Artery Occlusion Using Detachable Balloons

Iatrogenic cervical internal carotid artery pseudoaneurysm is a rare and potentially lethal complication following tonsillectomy. It can be complicated by thromboembolism, mass effect and eventually may rupture leading to death. Various endovascular treatment options are available for the management of these pseudoaneurysms, including coil embolization, detachable balloon occlusion, or stent graft placement. Parent artery occlusion using detachable balloons can be a therapeutic option in a subset of patients. However, evaluation of cross circulation with preprocedure balloon test occlusion is imperative in such cases.

Care of Infectious Conditions in an Observation Unit

Infectious conditions such as skin and soft tissue infections (SSTIs), Urogenital infections and peritonsillar abscesses frequently require care beyond emergency stabilization and are well-suited for short term care in an observation unit. SSTIs are a growing problem, partly due to emergence of strains of methicillin-resistant S. aureus (MRSA). Antibiotic choice is guided by the presence of purulence and site of infection. Purulent cellulitis is much more likely to be associated with MRSA. Radiographic imaging should be considered to aid in management in patients who are immunosuppressed, have persistent symptoms despite antibiotic therapy, recurrent infections, sepsis or diabetes.

Endovascular management of iatrogenic cervical internal carotid artery pseudoaneurysm in a 9-year-old child: Case report and literature review

Extracranial internal carotid artery (ICA) pseudoaneurysms are uncommon in the pediatric population and are usually secondary to direct trauma to the vessel. Treatment options include surgery (ligation), anticoagulation therapy and endovascular treatment. Endovascular covered stents have shown good results in adult populations, resulting in occlusion of the aneurysm and preservation of the artery without significant complications. However, there have been only limited reports in the literature reporting endovascular carotid stent placement in the pediatric population. We report a case of a 9-year-old boy patient, who developed a cervical ICA pseudoaneurysm after a parapharyngeal tumor resection. He was successfully treated by primary endovascular covered stent placement. During a follow-up of 6 months the patient has been asymptomatic, without any adverse event. Additionally, a literature review is done.

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.

Vessel-preserving stent-assisted coil embolization of an extracranial internal carotid artery pseudoaneurysm that developed after tonsillectomy in a pediatric patient: initial case report

Although there have been reports of carotid artery pseudoaneurysm formation after adenoidectomy and/or tonsillectomy secondary to iatrogenic injury, there are no case reports of successful endovascular reconstruction of the injured artery in the pediatric population. In most pediatric cases, the internal carotid artery (ICA) is sacrificed. The authors report on a 6-year-old girl who presented with odynophagia, left-sided Horner's syndrome, hematemesis, and severe anemia 6 months after a tonsillectomy. On examination she was found to have a pulsatile mass along the left posterior lateral oropharynx, and imaging demonstrated a dissection of the extracranial left ICA and an associated pseudoaneurysm. The lesion was managed endovascularly with stent-assisted coil embolization and ICA reconstruction. The child had a somewhat complicated postoperative course, requiring additional coil embolization for treatment of a minor recurrence of the pseudoaneurysm at 5 months after the initial treatment and then presenting with extrusion of a portion of the coil mass into the oropharyngeal cavity a year later. She underwent surgical removal of the extruded coils and repair of the defect and has since been free of symptoms or signs of recurrence. The authors conclude that this strategy definitively protected the patient against an oral exsanguination or aspiration event secondary to aneurysm rupture and reduced her risk of stroke by preserving vessel patency and caliber. Moreover, they note that covered stent reconstruction surrenders endovascular access and cannot immediately provide these benefits.

Traumatic Anterior Cerebral Artery Pseudoaneurysmal Epistaxis

BACKGROUND

Pseudoaneurysmal epistaxis is a rare but emergent condition. We report a case of traumatic anterior cerebral artery pseudoaneurysmal epistaxis and review the published literature.

CASE DESCRIPTION

A 49-year-old man sustained severe head trauma. He was diagnosed with multiple skull bone fractures, left subdural hematoma, subarachnoid hemorrhage, pneumocephalus, and right frontal hematoma. Subdural hematoma evacuation was done at a local hospital. In the following months, he experienced repeated epistaxis that required nasal packing to stop the bleeding. Digital subtraction angiography showed an anterior cerebral artery pseudoaneurysm protruding into the posterior ethmoid sinus. Embolization of the aneurysm was performed with microcoils, and the parent artery was occluded by thrombosis. The patient presented 1 month later with another epistaxis episode. Digital subtraction angiography showed recanalization of the parent artery and recurrence of the aneurysm. The parent artery was occluded for the second time with coils and Onyx embolic agent.

CONCLUSIONS

Pseudoaneurysmal epistaxis is rare, and this is the first report of an anterior cerebral artery pseudoaneurysm that manifested with epistaxis. Endovascular intervention has become the first choice of treatment for this disease. The high recurrence rate is the main disadvantage of endovascular intervention. Aneurysm trapping with bypass surgery is another treatment option.

Endovascular treatment of an infected pseudoaneurysm secondary to retropharyngeal abscess in a child

We describe a rare case of carotid pseudoaneurysm secondary to a retropharyngeal abscess, treated with coil embolization in a 2-year-old boy. The patient presented to an emergency department with symptoms suggesting meningitis but was subsequently diagnosed with streptococcal pharyngitis. He was discharged home on oral antibiotics after a short hospitalization. He returned to the emergency department two weeks later with limited neck motion and pain. Neck CT demonstrated a retropharyngeal abscess with a large left cervical internal carotid artery (ICA) pseudoaneurysm. The petrous ICA distal to the pseudoaneurysm had thrombosed prior to treatment. The ICA proximal to the pseudoaneurysm was sacrificed with coil embolization. Post-treatment imaging demonstrated complete thrombosis of the pseudoaneurysm but also demonstrated acute strokes in the left MCA/ACA watershed distribution. His parents noted that the patient was clumsier and exhibited some mild speech changes and a steppage gait prior to evaluation in the ED; therefore, these were thought to be secondary to emboli from partial thrombosis of the pseudoaneurysm prior to treatment. The patient was discharged home in good condition and his neurological function improved.

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.

Endovascular Occlusion of Cervical Internal Carotid Artery Pseudoaneurysm in a Child Treated by N-Butyl Cyanoacrylate: A Rare Case Report

We report a rare case of spontaneous extracranial cervical internal carotid artery (ICA) pseudoaneurysm in a female child aged 3 years who presented with a swelling in the neck which had bled following an attempted incision as it had been thought to be an abscess. A CT angiogram and an MR angiogram were not very conclusive to diagnose the exact site of origin and the morphology of the aneurysm. Digital subtraction angiography revealed a dissecting pseudoaneurysm of the right extracranial cervical ICA. The right ICA was ending as a pseudosac, and the right cerebral circulation was filling up through the right posterior cerebral artery. To minimize the radiation exposure, a microcatheter was placed inside the diagnostic catheter. The aneurysm sac was occluded using N-butyl cyanoacrylate since there was no distal flow to the brain from the artery beyond the aneurysm. It was a safe, effective and cheaper alternative to open surgery or to other endovascular management options available. Not all neck swellings are abscesses, and they should be examined and evaluated to exclude a vascular cause.

Endovascular treatment of post-pharyngitis internal carotid artery pseudoaneurysm with a covered stent in a child: a case report

CASE REPORT

We report a case of 4-year-old boy patient, who developed after a streptococcal pharyngitis a painful, pulsatile, and growing right-sided mass in the neck. Imaging studies revealed an extracranial right internal carotid artery pseudoaneurysm. The patient was successfully treated with stent-graft deployment. After 18 months of follow-up, the pseudoaneurysm is excluded from the circulation, the carotid artery is patent, and the patient is free from any neurological deficit.

DISCUSSION

Covered stents might be considered as a valid therapeutic option to treat carotid artery pseudoaneurysms.

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.