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

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.

Spontaneous internal carotid artery pseudoaneurysm complicated with ischemic stroke in a young man: A case report and review of literature

BACKGROUND

Carotid artery pseudoaneurysm (PSA) is infrequently encountered in clinical settings. Internal carotid artery (ICA) PSA complicated with ischemic stroke is rare. PSAs are typically caused by iatrogenic injury, trauma, or infection. The underlying mechanisms of spontaneous PSA formation are not well characterized. We report a healthy young man who presented with stroke as a complication of spontaneous PSA of the left ICA.

CASE SUMMARY

A 30-year-old man working as a ceiling decoration worker was hospitalized due to sudden-onset speech disorder and right lower extremity weakness. Medical history was unremarkable. Brain computed tomography revealed ischemic stroke. Digital subtraction angiography showed a left ICA PSA with mild stenosis. The patient was conservatively managed with oral anticoagulation and antiplatelet therapy. He recovered well and was discharged. The patient was in good condition during follow-up.

CONCLUSION

The occupational history of patient should be taken into consideration while evaluating the etiology of spontaneous ICA PSA in young people with stroke.

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.

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.

Middle cerebral artery infarction following common carotid compression due to a multiloculated parapharyngeal abscess

Deep neck space infections (DNSIs) include retropharyngeal and parapharyngeal abscesses. We report a rare complication of left-sided middle cerebral artery infarction precipitated by left common carotid artery compression secondary to a multiloculated parapharyngeal abscess. A 59-year-old woman with poorly controlled diabetes was admitted following a loss of consciousness. Examination demonstrated unilateral right-sided hemiparesis and computed tomography (CT) of the brain revealed an acute left-sided frontoparietal infarct. The patient had been complaining of a fever, left-sided ear redness and pain six days prior. Unfortunately, despite antibiotics in the community, her ear pain worsened to involve her left jaw. Closer examination revealed a swelling in her left submandibular region and a CT of her neck was performed, revealing a multiloculated left parapharyngeal abscess with evidence of left common carotid compression. A naso-pharyngo-laryngoscopy (NPLS) was performed to confirm the presence of an abscess. Owing to the size and complex location of the abscess, management via a prolonged antibiotic treatment was opted for over surgical intervention. After completion there was improvement in medical state and resolution on repeat NPLS. Vascular-related complications are rare following DNSI. Carotid artery compression has been reported, although current literature suggests it to be a benign phenomenon. Our case is the first reported instance of a parapharyngeal abscess with severe neurological complications, reminding physicians that such complications following a DNSI remain possible. Although rare, in the event of a cerebrovascular accident and sepsis, DNSI remains a possible cause to be considered.

Is vessel narrowing secondary to pediatric deep neck space infections of clinical significance?

INTRODUCTION

Pediatric deep neck space infections (DNSI) may cause internal jugular vein and/or carotid artery narrowing. Radiologists and otolaryngologists are often queried by emergency room providers and pediatricians with regards to the clinical significance when this radiographic finding is noted. There are often questions raised about need for further imaging, anticoagulation and overall management strategy. There is limited data to support our answers to these questions. This study investigated the clinical significance of vessel narrowing of the internal jugular vein and carotid artery in the setting of DNSI in children.

METHODS

208 patients over a 10 year period were reviewed in retrospective fashion. CT scans reports were evaluated for vessel narrowing, and clinical outcomes were analyzed.

RESULTS

This study found that nearly half (44.7%, 93 of 208) of pediatric DNSIs reviewed showed evidence of either carotid and/or internal jugular vein narrowing. There was no significant difference in vascular complications in those with vessel narrowing and those without (p = 0.09). There were no observed neurologic complications in either group.

CONCLUSIONS

Vessel narrowing is a very common finding in pediatric DNSI. Vascular complications are very rare, and importantly no patients had neurologic complications in either group (vessel narrowing or not). We found no evidence to support more aggressive surgical management, getting further imaging, starting anticoagulation, nor changing overall management strategy for patients based solely to the finding of vessel narrowing in DNSI.

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.