A curious case of a spontaneous infective native pseudoaneurysm of the internal carotid artery

We present a case of a 77-year-old patient who presented with a stroke. She subsequently became unwell and was found to have a spontaneous infective native carotid artery pseudoaneurysm. The patient was managed conservatively as per her wishes. Despite the rarity of this clinical diagnosis, clinicians should be aware of the pathophysiology of this entity and the available literature on management.

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.

Hybrid Solution for Mycotic Pseudoaneurysm of Carotid Bifurcation

Mycotic pseudoaneurysms of the extracranial carotid artery are rare and need surgical treatment to prevent rupture or embolization. We treated a case of a carotid bifurcation pseudoaneurysm secondary to infection caused by Staphylococcus epidermidis. We successfully treated it using a catheter balloon to obtain carotid bifurcation's control and replacing the carotid bifurcation with a vein graft. Management involves aneurysmectomy associated with antibiotic therapy and restoration of arterial continuity.

Resection of Internal Carotid Artery Aneurysm Under Neuroprotection With Flow Reversal Technique

Extracranial internal carotid artery (ICA) aneurysms account for <1.0% all aneurysms and a rare indication for carotid intervention. Causes include atherosclerotic degeneration, trauma, dissection, previous carotid surgery, connective tissue disorders, and infection. Authors report a case of a middle-aged male found to have a large aneurysm of the left ICA who underwent repair by resection and reconstruction with end-to-end anastomosis under neuroprotection with flow reversal. Our discussion includes a recommendation for this particular surgical repair. The patient in this case report has granted the authors consent for review of records and subsequent publication submission.

Mycotic pseudoaneurysm of the extracranial carotid artery, a severe and rare disease, a case report

BACKGROUND

Mycotic pseudoaneurysm of the carotid artery is a severe and rare disease. When it ruptures, it can produce severe morbidity and high mortality. It presents clinically as a pulsatile mass, usually diagnosable by computed tomography angiography with definitive confirmation achieved by establishing the presence of the pathogen in the tissue sample.

CASE PRESENTATION

We present the case of a 68-year-old male patient with a history of total laryngectomy. He presented with painful and pulsatile mass in his neck and, after precise evaluation, a ruptured carotid mycotic pseudoaneurysm was promptly detected and treated. After a surgical intervention and an adequate course of antibiotics, the patient successfully recovered.

CONCLUSIONS

Mycotic pseudoaneurysms of the extracranial carotid artery are uncommon and should always be surgically treated. Due to the high risk of potential complications, restoration of the arterial flow should be attempted in all occasions. High clinical awareness is imperative when approaching a mycotic pseudoaneurysm due to its wide spectrum of clinical symptoms, and must always be considered when diagnosing tumors of the neck. Despite its rarity, early detection and prompt treatment are critical to minimize the possibility of a fatal outcome.

Nontraumatic Vascular Emergencies of the Neck

Nontraumatic vascular emergencies of the head and neck are uncommon, but can occur in patients with central venous catheters, head and neck infections, and in patients with head and neck cancer. Recognizing the imaging findings of vascular complications in these patient populations is critically important to ensure expeditious treatment to avoid significant morbidity and mortality.

Ruptured Mycotic Aneurysm of the Common Carotid Artery: A Case Report

Mycotic aneurysms of the common carotid artery (CCA) are very rare and warrant surgical treatment to prevent rupture and death. A 89-year-old man who complained of a sore throat and swelling of the right side of neck. He had no history of trauma or neck infection. Physical examination revealed hard and pulsatile mass. Computed tomography showed initially pseudoaneurysm rupture on the right CCA with surrounding inflammation. The emergency operation revealed mycotic aneurysm rupture with CCA necrosis and was successfully done by wide debridement and carotid artery resection with interposition bypass. The resected tissue and blood culture grew growth of Staphylococcus aureus group. We report a rare case of mycotic aneurysm of right CCA that treated by bypass interposition.

Mycotic Aneurysm of the Common Carotid Artery as a Presenting Symptom for Early Colorectal Malignancy

Mycotic carotid aneurysms are rare vascular conditions that are associated with high mortality if left untreated. We present a gentleman who had a progressively enlarging tender pulsatile swelling on the right side of neck. Emergency computed tomography scan showed a large mycotic aneurysm arising from the right common carotid artery, and he underwent emergency open exploration with interposition bypass graft. Bacteroides fragilis species, which signified gastrointestinal-related sepsis, was isolated from the thrombus culture. Subsequently search of systemic septic source showed an early rectal adenocarcinoma. This is the first case in the world's literature of a patient who had B. fragilis mycotic carotid aneurysm as a presenting complaint of his occult rectal malignancy.

Staphylococcus hominis carotid artery infection with septic embolization

We present the case report of a Staphylococcus hominis carotid artery plaque infection, without mycotic aneurysm formation, that provided the nidus for septic embolization. The patient presented with transient neurologic symptoms, with no clinical signs or symptoms of sepsis. Multiple preoperative imaging modalities revealed critical carotid stenosis but no indication of an infection. Secondary carotid infection was discovered incidentally intraoperatively, and carotid reconstruction was completed with autogenous tissue. The patient transiently manifested sepsis only after the carotid reconstruction and recovered with the institution of parenteral antibiotics.

Internal Carotid Artery Aneurysm Mimicking Peritonsillar Abscess

The extracranial internal carotid artery aneurysm (EICAA) is an uncommon arterial lesion. Patients typically present with neurologic symptoms resulting from impaired cerebral perfusion and compression symptoms of cranial nerves. Often EICAA presents as a pulsatile neck mass, which is otherwise asymptomatic. We present a case of an 84-year-old female, who was initially referred to the Emergency Department for Otolaryngology with suspected peritonsillar abscess. The patient had a history of recent upper airway infection and cardiovascular comorbidities, including hypertension and ischaemic stroke complicated by extensive neurologic deficits. Physical examination revealed a compact, nonpulsatile mass in the lateral parapharyngeal space and local erythema of the mucosa. Duplex Doppler Ultrasonography and Computed Tomography revealed an atherosclerotic aneurysm of the right internal carotid artery, measuring 63 × 55 × 88 mm, stretching from the skull base to the angle of the mandible.

Hybrid endovascular and surgical approach for mycotic pseudoaneurysms of the extracranial internal carotid artery

Objectives:

Mycotic pseudoaneurysms of the extracranial internal carotid artery are rare, and their management often represents a challenge, but treatment is necessary due to the high risk of rupture and distal brain embolization. Systemic antibiotics associated with open surgical excision of the infected tissues and carotid reconstruction using autologous grafts are the treatment of choice. The use of endovascular techniques still remains controversial in infective fields; however, it can be an attractive alternative in high-risk patients or more often as a “temporary” solution to achieve immediate bleeding control for a safe surgical reconstruction.

Methods:

We discuss the unusual case of an extracranial right internal carotid artery mycotic pseudoaneurysm following methicillin-resistant Staphylococcus aureus infection, in a patient with poor general conditions.

Results and Conclusion:

The lesion was successfully treated using a hybrid endovascular and surgical procedure.

An internal carotid artery aneurysm presenting with dysarthria

A 72-year-old woman presented to her general practitioner with a 4-week history of right neck swelling. Clinical examination elicited a pulsatile mass consistent with a carotid artery aneurysm. Five days later the patient noticed her tongue movements had become awkward with associated dysarthria. Computed tomography confirmed a 4cm internal carotid artery aneurysm arising just distally to the carotid bifurcation. She proceeded to transfemoral diagnostic carotid angiography. Balloon occlusion of the right internal carotid artery origin was performed for a ten-minute period without any neurological deficit.

The decision was taken to proceed to surgical ligation of the origin of the internal carotid artery. Her symptoms of dysarthria have resolved.