Teaching Case

A 27-year-old man with a recent diagnosis of mononucleosis and angina from Candida albicans was hospitalised because of a sudden swelling of left side of the neck and difficulty in swallowing; he did not complain of nasopharyngeal bleeding. History was otherwise unremarkable; he specifically denied recent trauma and drug use.

A CT of the neck detected diffuse enlarged lymph nodes, a deep fluid collection of the left side of the neck consistent with haemorrhage and a leakage of contrast medium from the left common carotid artery (Fig. 1). No abscesses or neoplasms were evident. The rupture of the left common carotid artery was confirmed with a selective arteriography (Fig. 2). Since the patient was stable, a collegial consensus on conservative management was achieved; endovascular grafting was initially excluded to avoid infection of the stent itself and possible long-term complications of stenting. The patient was thus treated with hypotensive drugs, antibiotics and steroids. The day after the admission a CT demonstrated stop of the bleeding. Medical therapy was continued for a week. Ultrasonography follow-up demonstrated progressive disappearance of the cervical haematoma; a CT of the neck showed the complete restitutio ad integrum seven months late (Fig. 3).

Rupture of the extracranial carotid artery or its branches, known as carotid blow out (CBO), is a life-threatening occurrence usually due to malignancies, radiation therapy, trauma and infection of the head and neck [1-5]; spontaneous CBO without an apparent cause has also been reported [5-7]. According with clinical severity, patients with CBO can be divided in three groups [3]. Group I includes patients with “threatened” CBO, i.e. with evidence of exposed carotid artery prone to rupture if not protected with healthy tissue, or angiographic evidence of neoplastic invasion of the carotid artery or presence of a non-bleeding pseudoaneurysm. Patients in group II have a sentinel self-limiting haemorrhage or a haemorrhage controlled with surgical packing, whereas patients in group III suffer from a poor controlled hemorrhage [3]. Prognosis depends on the underlying disease, multiplicity of carotid ruptures, presence of cutaneous or pharyngeal fistula and infection [3, 5, 8]. Historically the treatment of choice was surgical ligation of the carotid artery, but nowadays endovascular treatment plays a major role. Permanent endovascular balloon occlusion, although less invasive, shares similar complications rate with surgery, clinical outcome depending on patency of the extracranial and intracranial arteries [3, 5]. Balloon occlusion may also be undertaken when reconstructive surgery of the carotid artery is planned. Coils embolisation of carotid artery, poorly effective in an acute CBO [9], can be performed for a carotid pseudoaneurysm in young patients [10].
Endovascular grafting of the carotid artery gives better results than transcatheter permanent balloon occlusion [3, 5]. Technically success depends on a favourable vascular anatomy and the type of device; self-expandable covered stent should be preferred because less traumatic and more compliant with regard to the carotid artery than premounted covered stents [5]. Endovascular grafting should be firstly preferred in older patients, in patients with CBO due to cancer or trauma or when haemorrhage is poorly controllable. However, some problems can arise in young patients with a CBO due to an infection of the neck. Conservative management is not the gold standard in CBO treatment, but it can be considered in a patient clinically stable with a single, tiny rupture of the carotid artery and without an evidence of a neck abscess; a strictly clinical observation is mandatory and the interventional team should be alerted for a prompt intervention to avoid a catastrophic outcome.