Infected "Mycotic" Aneurysm of the Common Carotid Artery-A Differential Diagnosis to Tumor of the Neck

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.

Mycotic Pseudoaneurysm: Clinical Course, Management and Prognosis

Pseudoaneurysm of vessels (most common in arteries), in general, happens when a blood vessel wall is damaged leading to leakage of blood and its collection in the surrounding tissue, essentially resulting in a false aneurysm. These false collections can be problematic and can develop in any location. However, their most common clinical presentation is in the femoral arteries. These manifest especially following an endovascular intervention. Here, we discuss a case of a 73-year-old male whose in-hospital course was complicated by the development and subsequent infection of a pseudoaneurysm after he was admitted for sepsis from a UTI. We further highlight the pathophysiology related to the formation of a pseudoaneurysm, and the mechanism of action behind various treatment modalities used. The clinical course and possible treatment options may vary. However, a robust combination of early surgical management alongside medical management seems to provide the best outcome.

Mycotic internal carotid artery pseudoaneurysm secondary to Mycobacterium tuberculosis

Mycobacterium tuberculosis is a rare causative agent for mycotic aneurysms of the extracranial carotid arteries. We describe a case of acute mycotic pseudoaneurysm and abscess in the right proximal internal carotid artery in close proximity to the carotid bifurcation, and subsequent management with antibiotic therapy, surgical debridement and resection with an end-to-end anastomosis.

Mycotic Aneurysm of Internal Carotid Artery Secondary to Livestock-associated Methicillin-resistant Staphylococcus Aureus Clonal Complex CC398

The aim of this article is to present a case of mycotic aneurysm of internal carotid artery secondary to livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) treated with resection and common-to-internal carotid artery bypass with autologous vein graft in a male pig farmer. A 69-year-old man, pig farmer, with recent dental extraction was admitted with a right cervical pulsatile mass, dysphonia, pain, leukocytosis and elevated C-reactive protein (CRP). Ultrasonography (US) and computed tomography angiography (CTA) showed a 3.9 × 4.5 cm mycotic aneurysm of right internal carotid artery with hypermetabolic uptake in positron emission tomography (PET) scan. Resection of the mycotic aneurysm and a common-to-internal carotid artery bypass with major saphenous vein graft were performed. LA-MRSA clonal complex (CC) 398 was detected in intraoperative samples and antibiotic therapy was changed according to antibiogram. Patient was discharged at the seventh postoperative day and received antibiotic therapy for 6 weeks. US 12 months later showed patency of the bypass without collections. Mycotic aneurysms of internal carotid artery are very infrequent. MRSA isolation is rare, and to the best of our knowledge this is the first case caused by multi-drug resistant LA-MRSA CC398. The treatment includes mycotic aneurysm resection and reconstruction with venous graft bypass plus intensive antibiotic therapy.

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.