Pseudoaneurysm of the superior thyroid artery following radiotherapy for hypopharyngeal cancer

Iatrogenic pseudoaneurysm of the superior thyroid artery after thyroidectomy

INTRODUCTION

A pseudoaneurysm arising from the superior thyroid artery is extremely rare. To the best of our knowledge, STA Pseudoaneurysm after thyroidectomy has not been reported.

CASE PRESENTATION

A 21-year-old female presented with anterior neck swelling of two years duration. Physical exam revealed a thyroid mass that measures 10 cm ∗ 8 cm. Neck US showed MNG (TIRADS 3) and FNAC suggested colloid goiter. Near Total Thyroidectomy was performed. On the 10th postoperative day, she noticed a painless, progressive left-sided neck swelling which is increasing in size with no active bleeding and no compressive symptoms. There is a 6x4cm tense pulsatile left-sided neck swelling adjacent to the thyroid cartilage and anterior to sternocleidomastoid muscle with a healed neck collar incision. CBC and coagulation profile were normal. Head and Neck CTA show aneurysmal dilatation of STA 3.8 cm × 3.2 cm with thrombosis of the posterior part of the lesion.

CLINICAL DISCUSSION

STA Pseudoaneurysms are quite rare events but could lead to catastrophic complications. Clinical manifestations can include pulsating painful mass in the neck, dysphagia, dyspnea, bleeding from the oral cavity, and cerebrovascular symptoms. It should be investigated with Color Doppler ultrasound, MRI and CTA.

CONCLUSION

In our case, the pseudoaneurysm occurred after thyroidectomy which has not been reported previously. The diagnosis was made by a computed tomography scan and the patient was treated by open STA ligation as endovascular service isn't available in our setup. Clinicians should therefore include pseudoaneurysm of STA or adjacent arteries in their differential diagnosis and intervene early to avoid devastating complications.

Rare Occipital Artery Pseudoaneurysm After Radical Neck Dissection

Pseudoaneurysm formation in the occipital artery, post radical neck dissection, leading to a bulging mass, is a rare but potentially fatal occurrence. The authors treated a patient with pseudoaneurysm of occipital artery, post radical neck dissection, presenting with pain and swelling after 17 days of surgery. A pseudoaneurysm involving occipital artery was revealed by digital subtraction angiography and treated by endovascular micro-coil embolization.

Bleeding complications in patients with squamous cell carcinoma of the head and neck

Hemorrhage in recurrent and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) may be attributed to chemotherapy and local tumor irradiation. Evidence of the relationship between hemorrhage in R/M HNSCC and targeted therapies, including epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) inhibitors, or immune checkpoint inhibitors, is limited. We aimed to identify epidemiological and clinical data related to the occurrence of hemorrhage in R/M HNSCC and to explore its relationship with various therapies. We describe information obtained from literature searches as well as data extracted from a commercial database and a database from the author's institution (Istituto Nazionale dei Tumori of Milan). Evidence suggests that most bleeding events in R/M HNSCC are minor. Clinical trial safety data do not identify a causal association between hemorrhage and anti‐EGFR agents or immune checkpoint inhibitors. In contrast, anti‐VEGF agents are associated with increased, and often severe/fatal, hemorrhagic complications.

Spontaneous rupture of an aneurysm of the superior thyroid artery: A rare cause of acute respiratory failure

Ruptured aneurysm of superior thyroid artery is a very rare pathological event. Underlying causes such as trauma, malignancy or iatrogenic are not systematically found. Resulting cervical hematoma is life threatening and can lead to acute respiratory failure, dysphagia, vocal cord paralysis and hemomediastinum. Endovascular treatment combined with surgical drainage has been described as an effective treatment. In this case report, a 63-year-old man presented a spontaneous rupture of an aneurysm of superior thyroid artery resulting in cervical hematoma and acute respiratory failure.

Transverse Cervical Artery Pseudoaneurysm: An Unusual Delayed Complication of Radical Neck Dissection

Pseudoaneurysm formation in the transverse cervical artery, post radical neck dissection, leading to massive hemorrhage, is a rare but life threatening occurrence. We report a patient with pseudoaneurysm of transverse cervical artery, post salvage radical neck dissection, presenting with recurrent and significant hemorrhage after 3 weeks of surgery. A pseudoaneurysm involving transverse cervical artery was revealed by digital subtraction angiography and treated by endovascular coil embolization.

Carotid blowout syndrome: modern trends in management

Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon complication of head and neck cancer that can be rapidly fatal without prompt diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity against the patient’s blood pressure, mainly in patients who have undergone surgical procedures and radiotherapy due to cancer of the head and neck, or have been reirradiated for a recurrent or second primary tumor in the neck. Among patients irradiated prior to surgery, CBS is usually a result of wound breakdown, pharyngocutaneous fistula and infection. This complication has often been fatal in the past, but at the present time, early diagnosis and modern technology applied to its management have decreased morbidity and mortality rates. In addition to analysis of the causes and consequences of CBS, the purpose of this paper is to critically review methods for early diagnosis of this complication and establish individualized treatment based on endovascular procedures for each patient.

Profuse bleeding from a pseudoaneurysm of the right superior thyroid artery after tracheostomy

Case

A 70-year-old man was brought to our hospital emergency department with accidental thermal burns. Surgical tracheostomy was carried out on day 8 after admission, followed by several profuse bleeding episodes from the orifice. Contrast-enhanced computed tomography of the neck revealed a small nodule with arterial phase enhancement that was suspected to be a pseudoaneurysm. During emergency angiography, the nodule was revealed to be a pseudoaneurysm arising from the right superior thyroid artery with contrast medium extravasation.

Outcome

The patient underwent transcatheter arterial embolization, which resolved bleeding from the tracheostomy orifice.

Conclusion

Pseudoaneurysm of the superior thyroid artery is an extremely rare and life-threatening tracheostomy complication. All clinicians certified to perform tracheostomy should be acquainted with the various complications and methods for managing life-threatening post-tracheostomy complications.

Onyx Embolization of a Ruptured Rotundum Foreman Artery Aneurysm in a Patient with Moyamoya Disease: A Case Report

BACKGROUND

Hemorrhage caused by the rupture of a rotundum foreman artery pseudoaneurysm in Moyamoya disease (MMD) is rarely reported.

CASE DESCRIPTION

We report a case of 46-year-old man with MMD presenting with left temporal lobe hemorrhage. Cerebral angiogram showed a pseudoaneurysm located on the rotundum branch of the left internal maxillary artery, which anastomosed with a pial vessel. Using onyx 18, we successfully embolized the pseudoaneurysm. The patient was discharged neurologically intact.

CONCLUSION

Given the difficulties and risks of surgery, onyx embolization of rotundum foreman artery aneurysm accompanied with MMD is feasible and effective.

Coil embolization in ruptured inferior thyroid artery aneurysm with active bleeding

We present a unique experience of urgent parent arterial embolization for treatment of an aneurysm of the inferior thyroid artery (ITA) that bled during tracheostomy. The event happened to a 69-year-old female patient with subarachnoid hemorrhage and hospital-acquired pneumonia that required tracheostomy. Abrupt and massive bleeding developed during the procedure, and the source could not be identified. Under manual compression, angiography revealed an 8-mm aneurysm that arose from the inferior thyroid artery. The superselected parent artery of the aneurysm was successfully occluded with a single pushable coil. The patient's postoperative course was uneventful.

CT angiography findings in carotid blowout syndrome and its role as a predictor of 1-year survival

BACKGROUND AND PURPOSE

Carotid blowout is a serious late complication of prior treatment of advanced head and neck cancer. We evaluate the efficacy of CTA in the diagnosis of impending carotid blowout syndrome in patients with head and neck cancer, and its capability to predict clinical outcome.

MATERIALS AND METHODS

The clinical data of 29 patients with impending carotid blowout who underwent CTA were collected and analyzed. Imaging signs included tissue necrosis, exposed artery, viable perivascular tumor, pseudoaneurysm, and contrast extravasation. DSA was obtained in 20 patients. One-year outcomes were compared based on management.

RESULTS

The most common CTA finding was necrosis (94%), followed by exposed artery (73%), viable tumor (67%), pseudoaneurysm (58%), and contrast extravasation (30%). Exposed artery, pseudoaneurysm, and contrast extravasation were the 3 CTA findings related to outcomes. All of the pseudoaneurysm and contrast extravasation cases were associated with an exposed artery. An exposed artery was the most important prognostic predictor and could not be diagnosed on DSA. Patients without the 3 findings on CTA (group 1) had the best survival rate at 1-year follow-up, followed by patients with the 3 findings treated immediately by permanent artery occlusion (group 2). Patients with the 3 findings who had no immediate treatment (group 3) had the worst outcomes (P < .001 in group 1 vs group 3 and group 2 vs group 3; P = .056 group 1 vs group 2).

CONCLUSIONS

CTA, with its ability to diagnose an exposed artery compared with DSA, may offer important management and prognostic information in patients with impending carotid blowout.

Management of hemorrhagic pseudoaneurysmal arteriovenous fistula of the sphenopalatine artery

n-Butyl cyanoacrylate (n-BCA) embolization of a hemorrhagic pseudoaneurysmal arteriovenous fistula of the sphenopalatine artery in a patient with paranasal sinus squamous cell carcinoma treated with regional surgery and radiation has, to our knowledge, not been previously reported.

Endovascular treatment paradigm of carotid blowout syndrome: review of 8-years experience

OBJECTIVES

Endovascular treatment is effective in treating carotid blowout syndrome (CBS). We reviewed our experience in addressing CBS over eight years and presented an account of the treatment paradigm and management algorithm.

METHOD

All cases of CBS from 2003 to 2010 with endovascular treatment performed in our center were reviewed. 15 CBS in 14 patients were recruited. Based on our management algorithm, treatment regimen was stratified into deconstructive or constructive methods. Their clinical presentations, angiographic features, angiographic and clinical outcomes were reviewed.

RESULTS

10 patients were treated with deconstructive method by means of permanent vessel occlusion (PVO) and 4 patients were treated with constructive method by means of placement of covered stent (n=3) or flow diverting device (n=1). Immediate hemostasis was achieved in all cases. 7 (50%) patients, in whom 5 treated with PVO and 2 with covered stent, had favorable outcomes and survived at a median follow-up period of 4 months (range: 1-84 months).

CONCLUSION

Permanent vessel occlusion remains the gold standard of treatment and tends to show a favorable long-term outcome. Off-label use of covered stent and flow-diverting device can produce satisfactory results should balloon occlusion test fail, but long-term follow up would be required for definitive assessment.

Pseudoaneurysm of the inferior thyroid artery presenting as a thyroid nodule

A 63-year-old woman complained of a growing neck mass. Sonography revealed a solid and cystic mass in the right thyroid lobe. Color Doppler study and computed tomography revealed anechoic cystic portions within the thyroid nodule to be a pseudoaneurysm arising from the right inferior thyroid artery. The only identifiable risk factor was a past thyroid needle biopsy performed approximately 5 years previously according to the patient's recollection. Right lobectomy was performed and the pseudoaneurysm was treated without complication.

Radiation carotid blowout syndrome in nasopharyngeal carcinoma: angiographic features and endovascular management

OBJECTIVE

To report clinical manifestations, angiographic features, and outcomes of endovascular management in 14 patients with 15 radiation carotid blowout syndromes of nasopharyngeal carcinomas.

STUDY DESIGN AND SUBJECTS

Retrospective chart review of 14 patients with nasopharyngeal carcinomas (mean age 49 years) with 15 radiation carotid blowout syndromes who had undergone endovascular embolization to manage oronasal bleeding in the past 10 years.

RESULTS

Average radiation dose to affected carotid artery was 73 gray units (latent period: 33 months). Radiation carotid blowout syndrome was detected in internal (n = 10), external (n = 4), or common carotid artery (n = 1). Detachable balloons were used in 11 affecting arteries for vascular occlusion; 4 were treated by liquid adhesives or coil. Endovascular treatment was successful in all 15 radiation carotid blowout syndromes with cessation of hemorrhage. One patient had hemiparesis after embolization. Mean clinical follow-up was 21 months.

CONCLUSION

Radiation carotid blowout syndrome in nasopharyngeal carcinoma may occur in various periods or arteries. Endovascular embolization provides both safe and effective management.

Ruptured pseudoaneurysm of the internal maxillary artery complicating CT-guided fine-needle aspiration in an irradiated, surgical bed

BACKGROUND

CT-guided fine-needle aspiration (FNA) is a safe procedure, but major complications can occur rarely. Pseudoaneurysm rupture in the head and neck region following CT-guided FNA is an emergency that can result in life-threatening hemorrhage. This case emphasizes the salient risk factors for pseudoaneurysm formation and rupture in the head and neck region following CT-guided FNA.

METHODS

A patient was seen with oral and facial hemorrhage as a result of a ruptured pseudoaneurysm 11 weeks following CT-guided FNA in a previously irradiated surgical bed.

RESULTS

The patient was treated with coil embolization in and around the pseudoaneurysm and discharged without any further complications.

CONCLUSIONS

Although CT-guided FNA is a safe and effective procedure, some patients may be at increased risk for rare but major complications. Caution should be used in proceeding with CT-guided FNA in an irradiated surgical bed of the head and neck.

Pseudoaneurysm of internal carotid artery following mandibular reconstruction treated by covered stent

SUMMARY

We describe the case of a 68-year-old woman who had a mandibular titanium plate reconstruction following surgery for a parotid carcinoma. Fifteen months later she presented bleeding episodes related to a pseudoaneurysm of the internal carotid artery located just above the bulb. This was probably related to the weakening of the arterial wall following friction with the mandibular plate and radiotherapy.We successfully obliterated this pseudoaneurysm using a covered stent. This rare diagnosis should be evoked in case of bleeding following a mandibular reconstruction. Stenting is an effective treatment strategy obviating the need for open surgery.

Carotid stenting for symptomatic radiation-induced arteritis complicated by recurrent aneurysm formation

We describe a 56-year-old male who underwent successful carotid stenting (CS) with adjuvant distal protection in response to symptomatic radiation-induced carotid disease. During the CS procedure, it was incidentally noted that the lesion yield pressure was surprisingly low (2 atm). The patient returned with local symptoms from common carotid aneurysmal dilation at the proximal edge of the stent that was successfully treated with a stent graft. A second aneurysm developed proximal to the stent graft and, based on intravascular ultrasound mapping, he ultimately underwent venous bypass covered by a free-muscle graft. We believe the low lesion yield pressure in this case reflected loss of vessel integrity and it may be prudent to avoid oversizing the stent in such patients.

Contemporary management of carotid blowout

PURPOSE OF REVIEW

The purpose of this report is to summarize existing literature with respect to carotid artery blowout and to present an up-to-date algorithm for its management that incorporates recent advances with respect to its diagnosis and treatment.

RECENT FINDINGS

Although once thought as one entity, carotid blowout is now considered to be a syndrome with clinical manifestations ranging from acute hemorrhage to asymptomatic exposure of a carotid artery. As a result, carotid blowout syndrome can present as one of three separate entities: threatened, impending, and acute carotid blowout. In recent years newer approaches to management have centered around the use of diagnostic angiography followed by definitive therapy with either carotid occlusion by coils, detachable balloons, or endovascular stents. Overall morbidity of management has decreased.

SUMMARY

Interventional radiologic techniques have revolutionized the treatment of carotid blowout syndrome, allowing more accurate diagnosis and lower treatment morbidity.