Progressive laterocervical mass after 4 days carotid endarterectomy procedure: Active bleeding from rigth carotid

Clinical History

85y/o patient presented with an ischaemic stroke affecting the right PCA and MCA territories. They had a right ICA stenosis >80% at the carotid bifurcation. A conventional endarterectomy was performed, immediately complicated by a perioperative haematoma that was surgically drained. Four days later a rapid progressive laterocervical mass was detected.

Imaging Findings

CT angiography and delayed phase imaging was performed.

Imaging findings were consistent with a large cervical haematoma in the right carotid space that compressed the ipsilateral jugular vein and adjacent cranial nerves; it was also displacing and compromising the airway to the left.
Hyperattenuating extravasated contrast material was depicted outside the lumen of the right internal carotid artery consistent with a diagnosis of active carotid bleeding.
Curved MPR, MIP and VRT reconstructed images were also analysed.

Discussion

The objective of carotid endarterectomy is to prevent stroke as it still remains a significant contributor to morbidity and mortality in developed countries.

The American Heart Association recommendations for surgery are in symptomatic patients with 70-90% carotid stenosis and asymptomatic patients with acceptable surgical risk with >70% diameter reduction of distal outflow tract [1]

Steps in a conventional operative technique include making a cervical incision parallel and anterior to sternocleidomastoid and centred over the carotid bifurcation. This incision can be extended to the sternal notch for more proximal lesions of the common carotid artery (CCA) and distally to the mastoid process for higher exposure. The arteriotomy should extend distal to the plaque until it reaches a point where the artery is relatively normal. Conventional endarterectomy is normally closed with a patch angioplasty. In our centre prosthetic patch Dacron/politetrafluoroethylene is used. [2]

Complications of this technique such as infection and false aneurysm formation are extremely rare.
Flow related complications as hypotension or hypertension and cranial nerve dysfunction after surgery are relatively common but transient complications [3].

In the literature, the incidence of wound haematomas requiring reoperation, as in our case, varies from 2-2.5% [5, 6]. The use of antiplatelet agents and intraoperative heparin anticoagulation contribute to this bleeding risk.

Our patient presented with a progressive laterocervical mass within 3 hours of surgery.
Acute swelling in the neck after a surgical procedure warrants immediate imaging.

CT angiography was performed as a technique that provides high-resolution and high contrast images of the arterial lumen and wall. Two-dimensional and 3D visualization methods are routinely employed to create images comparable to those acquired with conventional angiography. Venous phase of the neck was acquired as well, 60s after contrast material injection.

The CT diagnosis of active carotid bleeding is made when hyperattenuating extravasated contrast material is seen outside the vessel lumen.

Significant perioperative haematomas should be surgically drained.
In our case immediate surgery was performed after CT acquisition and the patient did well.

Teaching points:
- CT angiography plays an important role in the evaluation and localization of acute, active haemorrhage in any body location.
- The use of ultrasound in this acute setting is limited. Although it is an ideal initial imaging investigation for neck masses, CT has major advantages over US as it is extremely fast and its time burden is often less than that of a US examination. US is operator-dependent and images are less easily reviewed by others.

Differential Diagnosis List

Final Diagnosis

Post-surgical carotid haematoma

URL:	https://www.eurorad.org/case/14098
DOI:	10.1594/EURORAD/CASE.14098
ISSN:	1563-4086