Cavernous hemangioma of the external carotid artery Francesco Massi, MD,a Marco Massi, MD,b Lucia Torracca, MD,a and Gaetano Thiene, MD, FRCP, FESC,c Ancona, Macerata, and Padua, Italy
A 71-year-old woman presented with sudden headache, hypertension, and recurrent right periorbital pain. The patient’s anamnesis was negative for cardiovascular or neurologic pathology. Head and neck magnetic resonance angiography and computer tomography showed an oval vascularized mass (20 24 mm) in close proximity to the bifurcation of the left carotid artery (A; the black arrows are pointing to an oval vascularized mass distal to the carotid bifurcation). No lymphadenopathy was detected. Asymptomatic paraganglioma or an aneurysm of the facial artery were proposed as differential diagnoses. The patient reported no dysphagia, dysphonia, or previous trauma to the neck. The mass was laterally displacing, nonpulsatile, and without detectable bruit. Surgical excision was considered the treatment of choice for both paraganglioma and facial artery aneurysm. An encapsulated mass situated between the left internal and external carotid arteries, underneath the hypoglossal nerve, was discovered (B and C). It was vascularized by collateral vessels of the left external carotid artery, and resection was performed by ligating them without arterial clamping. Histologic analysis (hematoxylin-eosin stain 40, actin immunohistochemistry) suggested a cavernous hemangioma with large thin-walled blood vessels, lined by endothelial cells and separated by fibrous tissue (D). The patient was discharged on the fifth postoperative day. Six months after surgery, she was in good clinical condition, without echocardiographic signs of relapse of the mass. DISCUSSION Hemangiomas are benign neoplasms often located superficially in the head and neck. They usually are unapparent at birth and have a period of rapid growth during early infancy, followed by gradual involution.1 Deep hemangiomas tend to grow later and longer than superficial ones. Patients often remain asymptomatic or present with nonspecific symptoms, such as headache. This is the first hemangioma to be reported in the carotid sheath distal to the carotid bifurcation.2,3 Carotid sheath hemangiomas may be easily misdiagnosed as arterial aneurysms, neurogenic tumors, paragangliomas, or lymphatic masses.3 Such neck masses should be investigated carefully with ultrasound scanning, magnetic resonance angiography, and computed tomography, and surgical removal is the treatment of choice. In this case, only surgical excision and histologic examination could reveal the true nature of the mass. We advocate a high level of awareness for vascular anomalies in adults, even if rare, to avoid misdiagnosis, complications, or intraoperative “discoveries.” The authors would like to thank Dr Tamara Gliha Valic and Mr Alexander Stoll for proofreading. From the Department of Cardiac Surgery, Ospedali Riuniti di Ancona, Anconaa; the Department of Vascular Surgery, Ospedale Generale Provinciale, Maceratab; and the Department of Medical Diagnostic Science and Special Therapies, Cardiovascular Pathology, University of Padua Medical School, Padua.c Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:525-6 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.09.005
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REFERENCES 1. Werner JA, Dünne AA, Folz BJ, Rochels R, Bien S, Ramaswamy A, et al. Current concepts in the classification, diagnosis and treatment of hemangiomas and vascular malformations of the head and neck. Eur Arch Otorhinolaryngol 2001;258:141-9. 2. Zagzag J, Morris LG, DeLacure MD. Cavernous hemangioma of the carotid sheath. Otolaryngol Head Neck Surg 2009;140:608-9. 3. Antonopoulos C, Karagianni M, Zolindaki C, Anagnostou E, Vagianos C. Cavernous hemangioma of infrahyoid carotid sheath and review of the literature on carotid sheath tumors. Head Neck 2009;31:1381-6. Submitted Jul 12, 2012; accepted Sep 1, 2012.
A 71-year-old woman presented with sudden headache, hypertension, and recurrent right periorbital pain. The patient’s anamnesis was negative for cardiovascular or neurologic pathology. Head and neck magnetic resonance angiography and computer tomography showed an oval vascularized mass (20 24 mm) in close proximity to the bifurcation of the left carotid artery (A; the black arrows are pointing to an oval vascularized mass distal to the carotid bifurcation). No lymphadenopathy was detected. Asymptomatic paraganglioma or an aneurysm of the facial artery were proposed as differential diagnoses. The patient reported no dysphagia, dysphonia, or previous trauma to the neck. The mass was laterally displacing, nonpulsatile, and without detectable bruit. Surgical excision was considered the treatment of choice for both paraganglioma and facial artery aneurysm. An encapsulated mass situated between the left internal and external carotid arteries, underneath the hypoglossal nerve, was discovered (B and C). It was vascularized by collateral vessels of the left external carotid artery, and resection was performed by ligating them without arterial clamping. Histologic analysis (hematoxylin-eosin stain 40, actin immunohistochemistry) suggested a cavernous hemangioma with large thin-walled blood vessels, lined by endothelial cells and separated by fibrous tissue (D). The patient was discharged on the fifth postoperative day. Six months after surgery, she was in good clinical condition, without echocardiographic signs of relapse of the mass. DISCUSSION Hemangiomas are benign neoplasms often located superficially in the head and neck. They usually are unapparent at birth and have a period of rapid growth during early infancy, followed by gradual involution.1 Deep hemangiomas tend to grow later and longer than superficial ones. Patients often remain asymptomatic or present with nonspecific symptoms, such as headache. This is the first hemangioma to be reported in the carotid sheath distal to the carotid bifurcation.2,3 Carotid sheath hemangiomas may be easily misdiagnosed as arterial aneurysms, neurogenic tumors, paragangliomas, or lymphatic masses.3 Such neck masses should be investigated carefully with ultrasound scanning, magnetic resonance angiography, and computed tomography, and surgical removal is the treatment of choice. In this case, only surgical excision and histologic examination could reveal the true nature of the mass. We advocate a high level of awareness for vascular anomalies in adults, even if rare, to avoid misdiagnosis, complications, or intraoperative “discoveries.” The authors would like to thank Dr Tamara Gliha Valic and Mr Alexander Stoll for proofreading. From the Department of Cardiac Surgery, Ospedali Riuniti di Ancona, Anconaa; the Department of Vascular Surgery, Ospedale Generale Provinciale, Maceratab; and the Department of Medical Diagnostic Science and Special Therapies, Cardiovascular Pathology, University of Padua Medical School, Padua.c Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;59:525-6 0741-5214/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.09.005
525
526 Massi et al
JOURNAL OF VASCULAR SURGERY February 2014
REFERENCES 1. Werner JA, Dünne AA, Folz BJ, Rochels R, Bien S, Ramaswamy A, et al. Current concepts in the classification, diagnosis and treatment of hemangiomas and vascular malformations of the head and neck. Eur Arch Otorhinolaryngol 2001;258:141-9. 2. Zagzag J, Morris LG, DeLacure MD. Cavernous hemangioma of the carotid sheath. Otolaryngol Head Neck Surg 2009;140:608-9. 3. Antonopoulos C, Karagianni M, Zolindaki C, Anagnostou E, Vagianos C. Cavernous hemangioma of infrahyoid carotid sheath and review of the literature on carotid sheath tumors. Head Neck 2009;31:1381-6. Submitted Jul 12, 2012; accepted Sep 1, 2012.
