Occult carotid pseudoaneurysm following streptococcal throat 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.

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.

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.

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.

Unusual angiographic changes in an internal carotid artery pseudoaneurysm after infection in the deep neck space

A 48-year-old man presented with a pseudoaneurysm at the cervical portion of the left internal carotid artery (ICA) secondary to infection in the deep neck space. Magnetic resonance (MR) imaging demonstrated enhancement of the wall of the ICA and a pseudoaneurysm, considered to be sequelae of infection spread. ICA occlusion occurred on the next day resulting in sudden onset of right hemiparesis and motor aphasia. The ICA pseudoaneurysm shrank gradually and his neurological deficits improved with conservative therapy. One month later, he presented with aneurysm regrowth. The common carotid artery was occluded with Guglielmi detachable coils to block arterial flow into the pseudoaneurysm. There were no neurological complications. Marked enhancement of the ICA wall on computed tomography and MR imaging may indicate the possibility of vascular complications such as rupture, pseudoaneurysm development, or ICA occlusion, and consequent neurological deficits. ICA occlusion caused by spread of infection in the deep neck space may cause accelerated coagulopathy due to ICA wall inflammation.

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

BACKGROUND

Extracranial carotid artery aneurysms (ECAAs) are very rare conditions in children but carry a great potential of thromboembolic episodes and ruptures.

METHODS

To determine the clinical and therapeutic characteristics of ECAA in children in our department, we reviewed the patients' records and completed the data from phone correspondence, written survey, and clinical examination.

RESULTS

From January 1981 to June 2006, 4 patients younger than 18 years were surgically treated for ECAA in our department. They were 3 boys and 1 girl. A medical history of tonsillectomy was reported in 3 patients. The aneurysm was symptomatic in all of the patients, local signs being present in every patient. The aneurysm caused hemispheric symptoms in 1 patient and finally stroke. The aneurysms were located in the common carotid artery, in the external carotid artery, and 2 in the internal carotid artery. The cause was congenital, mycotic, and traumatic (post tonsillectomy); for 1 patient, the etiology remained unknown. Aneurysm resection and interposition with vein graft were performed in 3 patients. The external carotid artery aneurysm was resected without reconstruction. There was no perioperative death or stroke. During the early follow-up period, 1 patient had a transient dysphagia and another a transient facial palsy. The patient with preoperative stroke remained with a neurologic deficit. All these patients were followed since the operation. The patient operated on in 1981 is asymptomatic after 25 years, but the graft became occluded 3 years after the operation. The patient who had recurrent attacks is still with residual neurologic deficit. The 2 other patients are without complains; the reconstructions remain patent.

CONCLUSION

Although very rare, ECAA can be encountered even in the pediatric population. The past medical history may reveal a tonsillectomy, although the relation may not be easy to establish. Local signs may be accompanied by hemispheric thromboembolic complications, rupture, and bleeding. Therefore, surgical treatment is indicated, but can be challenging according to the anatomical location of the aneurysm.

Evaluation of acute trismus by MRI: a case report. Bilateral peritonsillar cellulitis

We describe a rare case of a bilateral peritonsillar cellulitis (PTC). The clinical presentation of fever, trismus and odynophagia was consistent with PTC, more evident on the right side; but the presence of bilateral tonsillar swelling and midline uvula confounded the diagnosis. In spite of the throat examination was performed with a great difficulty due to trismus, the T2 weighted fat saturated STIR magnetic resonance imaging (MRI) guided us to make the diagnosis and to start the intravenous antibiotic treatment immediately.