CASE 13349 Published on 18.02.2016

Pseudoaneurysm of the common carotid: an unusual complication of behcet's disease

Section

Head & neck imaging

Case Type

Clinical Cases

Authors

Taam.I, Boussouni.K, Jroundi.L

Rabat 10000 Rabat, Morocco; Email:ik-med@hotmail.fr
Patient

37 years, female

Categories
Area of Interest Vascular ; Imaging Technique CT-Angiography, Ultrasound-Colour Doppler
Clinical History
A 37-year-old female patient was admitted to our hospital with a pulsating mass in the left side of her neck and dyspnoea. The neck mass had developed five days prior to admission. The patient had no history of neck trauma.
Imaging Findings
The patient had been diagnosed with Behcet’s disease five years prior to admission to the hospital, suffered from deep vein thrombosis related to her disease, and was being treated with prednisolone.

Physical examination revealed an approximately 7 cm sized painless, pulsating mass on the left neck. The neurological examination was normal. The patient’s vital signs were stable.

A contrast-enhanced computed tomography (CT) of the neck was performed and showed a 70x70x65mm (AP x W x H) pseudoaneurysm of the left common carotid situated 9mm proximal to the bifurcation.There was mass effect on adjacent structures notably the oesophagus and the trachea without significant stenosis, and the left internal jugular vein was compressed.

An ultrasound colour Doppler confirmed the presence of a pseudoaneurysm of the common left carotid artery with biphasic flow.

Urgent surgery was deemed necessary to prevent fatal complications of this rapidly expanding pseudoaneurysm.
Discussion
A pseudoaneurysm is a hematoma that forms as the result of a leaking hole in an artery. It arises when a tear occurs in the wall allowing blood to leak into surrounding tissues, with persistent communication between the arterial lumen and the blood-filled cavity . The main difference between a true aneurysm and a pseudoaneurysm is the lack of an adventitia in a pseudoaneurysm, where the whole wall is lacerated [1].

Vessels involved in Behcet’s Disease often present with thrombophlebitis and venous thrombosis [2]. Arteries are seldom involved and extracranial carotid pseudoaneurysms are rarer than those affecting the aorta, pulmonary and femoral arteries [3].

In Behcet's disease, aneurysms develop at an early age, as in this case.

There are two forms of pathogenesis, the first is due to thinning of the tunica media, which can lead to rupture of the internal or external elastic lamina. The second is vasculitis with lymphocytic infiltration in the vaso vasorum [4].

The most common site of extracranial carotid artery pseudoaneurysms is the external carotid artery while aneurysms often involve the bifurcation of the common carotid artery [5]. In our case, the pseudoaneurysm was located 9 mm proximal to the carotid bifurcation.

Common carotid artery pseudoaneurysm can be asymptomatic or present as a pulsating cervical mass. This mass can compress the upper airways leading to dyspnoea as in this case. Rarely, it can lead to recurrent laryngeal nerve palsy and Horners' syndrome [1].

The diagnosis of pseudoaneurysms may be made with Doppler ultrasound, CT Angiography (CTA), MRI and angiography [5].

Conventional radiographs may show a homogeneous cervical opacity of water density. Doppler ultrasound confirms this to be of vascular origin and permits blood-flow assessment
On CTA the pseudoaneurysm is a mass that enhances homogeneously in continuity with a blood vessel [6].
CTA is the preferred modality since it provides information about the feeding artery to the pseudoaneurysm, and the status of the intracranial circulation

Because the rupture of a pseudoaneurysm can be fatal, operation is recommended. The methods adopted by surgeons include open surgery, such as restoring blood flow with a bypass , as this case, or repairing with a patch [7] and endovascular therapy, such as administrating stents, vein covered stent or coils [8].
Differential Diagnosis List
Pseudo aneurysm of the common carotid: complication of Behcet's disease
true aneurysm
common carotid artery dissection
Final Diagnosis
Pseudo aneurysm of the common carotid: complication of Behcet's disease
Case information
URL: https://www.eurorad.org/case/13349
DOI: 10.1594/EURORAD/CASE.13349
ISSN: 1563-4086
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