SPONTANEOUS RUPTURE OF THE COMMON CAROTID ARTERY: A CASE REPORT Kwang Hyun Kim, MD, Myung Whun Sung, MD, and Seung Ha Oh, MD

Spontaneous rupture of the common carotid artery is an extremely rare vascular disorder in the head and neck region. Pseudoaneurysm can be formed by arterial rupture, presenting clinically as an expanding mass lesion. A 37-year-old fisherman suffered from the spontaneous rupture of the left common carotid artery and resultant pseudoaneurysm was radiologically recognized. Surgical exploration revealed a 0.5-cm rent in the common carotid artery, 2 cm proximal to the bifurcation. The lesion was successfully managed with polypropylenesutures during temporary clamping of the carotid artery. The literature is reviewed and the principles of management are discussed. HEAD & HECK 1992;14:496-501 0 1992 John Wiley & Sons, Inc.

Rupture of the common carotid artery is an extremely uncommon vascular lesion in the head and neck region. It can be caused by the rupture of an enlarging aneurysm which originates as a result of the loss of structural integrity of the vessel wall and the turbulence distal to an anatomic constriction. Preoperative radiotherapy, orocutaneous fistula with infection, and invasion of the vessel wall by tumor are predisposing conditions of occasional rupture of the carotid artery.

From the Department of Otolaryngology, Seoul National University, College of Medicine, Seoul, Korea. Address reprint requests to Dr. Kim at the Department of Otolaryngology, Seoul National University, College of Medicine, 28 Yongon-Dong Chongno-Ku, Seoul, 110-744, Korea. Accepted for publication April 20, 1992. CCC 0148-640319’21060496-06 0 1992 John Wiley & Sons, lnc.

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The authors describe herein a case of pseudoaneurysm due to the spontaneous rupture of the common carotid artery. Clinical manifestations, etiologic factors, and operative management of this patient are discussed. CASE REPORT

A 37-year-old fisherman was admitted to the Department of Otolaryngology, Seoul National University Hospital, on September 24, 1989, complaining of a tender mass in the left anterior region of the neck. Three days before admission, when he was dragging a fishing net, he noticed a sudden formation of a tender mass with mild dyspnea, and hoarseness. Computed tomography (CT) of the neck obtained at another hospital showed a suspicious carotid artery aneurysm (Figure l),he was then transferred to our hospital. He had no episode of trauma to the neck except straining on dragging the net. His medical and family history were not contributory. Blood pressure was 130/80 mmHg and other vital signs were within normal limits. The left side of the neck showed diffuse bulging and the skin of the neck was discolored due to subcutaneous hemorrhage. The larynx was displaced toward the opposite side. Palpation revealed a tender fixed mass in the left carotid triangle area, which was rubbery, firm, pulsatile, and about 6 cm in diameter. Auscultation revealed a systolic bruit. Submucosal ecchymosis of the mucosa of the left pharyngeal wall was noted. The neurologic examination was within normal limit.

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FIGURE 1. Preoperative postcontrast axial CT of the neck. A large mass (arrowheads) with dense contrast enhancement is demonstrated in the left parapharyngeal space. Left common carotid artery (arrow) is displaced laterally, and the internal jugular vein is not opacified.

The results of the peripheral blood examination and blood chemistries were normal. Tests for coagulation disorders indicated no abnormality. Serologic test for syphilis, candida antigen, and AIDS were negative. Electrocardiogram was normal. Chest radiograph and cervical spine view showed displacement of the larynx and trachea toward the right. A sonogram taken on the day after the admission revealed a pulsatile hypoechogenic cavity with huge thrombi. TFCA (transfemoral carotid angiogram) revealed a large aneurysmal sac opacified by the leakage of contrast material, just inferior t o the bifurcation of the common carotid artery. During angiography, occlusion tolerance test was carried out by occluding the carotid artery proximal to the rupture with a balloon for 30 minutes, and it was confirmed that the collateral blood flow to the ipsilateral hemisphere was adequate. Intravenous DSA (digital subtraction angiography) also revealed findings similar to that of the TFCA (Figure 2). Under general anesthesia, an incision along the anterior border of the sternocleidomastoid muscle was made and the retraction of the muscle posteriorly revealed Operative Procedure and Findings.

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FIGURE 2. Preoperative intravenous DSA with anteroposterior projection. Left carotid artery is displaced laterally, and a large aneurysmal sac (arrows) is opacified by the leakage of contrast material. Both carotid and vertebral arteries are simultaneously opacified by the intravenous contrast injection.

a pulsatile mass. The external jugular vein and the superior thyroid artery were ligated and cut. The mass, 6 cm in diameter, was located between the common carotid artery and the thyroid cartilage. The mass, alleged to be a hematoma from the rent of the carotid, had been fixed to surrounding tissues, compressing the internal jugular vein (Figure 3). Two strips of umbilical tape were passed under the carotid artery, one proximal to the hematoma, and the other under the internal carotid artery above the bifurcation. During a careful dissection of the hematoma sac, a sudden gush of blood occurred. Because the result of the occlusion tolerance test was good, we thought that a shunt was not essential during a brief vascular repair and a temporary clamping of the proximal and distal part of the rupture site would be enough.

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FIGURE 3. The mass (M) located between the carotid artery and the thyroid cartilage displaces the carotid artery (C) posteriorly. The vagus nerve (arrowheads) and severely narrowed internal jugular vein (arrow) are identified.

the rent was so small, no more biopsies were taken from the normal appearing carotid wall. It was difficult to remove the wall of the sac because of its fibrous adhesion; therefore, it was left widely open (Figure 4). The dead space was obliterated by rotating a strap muscle flap. The postoperative period was uneventful, and no neurologic sequelae were present. The postoperative intravenous DSA, obtained 3 weeks after the surgery, showed no leakage of contrast material but did demonstrate focal narrowing of the lumen at the distal portion of the common carotid artery, representing the site of rupture and primary closure (Figure 5). The biopsy taken from the wall of the hematoma showed only the adventitial layer of the artery without muscular layer of the media. According to the finding, the sac was thought to be a pseudoaneurysm (Figure 6).

While controlling this bleeding with umbilical tape and hemostat, a 5-mm longitudinal rent was found on the medial side of the common carotid artery, 20 mm proximal to the bifurcation. The wall of the carotid seemed to be normal except the rent, which was closed by two horizontal mattress sutures using 5-0 polypropylene suture. To eliminate possible air embolism, the vessel was compressed digitally before completion of the closure. The procedure took no more than 5 minutes. The hematoma sac was opened and thrombi were removed. A biopsy was taken from the hematoma wall near the rent. Because the other parts of the carotid artery displayed no evidence of disease by inspection or palpation, and

FIGURE 4. The carotid rent has been sutured primarily (arrow). The false aneurysmal sac (A) is opened widely and internal thrombi (T) are evacuated.

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FIGURE 5. Postoperative intravenous DSA with oblique projection. No aneurysmal sac is opacified. A focal luminal narrowing (arrow) at the distal common carotid artery, which represents the point of rupture and primary closure, is seen. The flow of the left carotid artery is as good as normal on the opposite side.

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FIGURE 6. Microscopic examination shows only the adventitial layer (A) with a thrombus, which is organized and causing revascularization (V). There was no muscular layer of the media. Hematoxylin & eosin; original magnification, x 100.

DISCUSSION

Shumrick' listed three main contributing factors of the carotid artery rupture; preoperative radiotherapy, orocutaneous fistula with infection, and a combination of radiotherapy and fistula. Another factor that increases the probability of carotid artery rupture is invasion of the vessel wall by tumor and infection. Spontaneous rupture of the carotid artery is extremely rare.2,3 Two factors implicated in the pathogenesis of an arterial aneurysm are the loss of structural integrity of the vessel and the turbulence below the A pseudoaneusite of the anatomic con~triction.~ rysm, or false aneurysm, begins as an incomplete vascular laceration or partial transection that remains enclosed within the soft tissues surrounding the ~ e s s e l .Sepsis, ~ , ~ syphilis, and mycotic infection has been common etiologic factors of the extracranial carotid aneurysms before antibiotics were in common use. Nowadays, trauma and atherosclerosis account for the majority of these aneurysm~.~-' Other causes include congenital medial defect, fibromuscular dysplasia, and, rarely, Marfan's syndrome. In some patients, however, the etiology is ~ n c e r t a i n . ' - ~ ' ~ ~ - ~ ~ In this case, we performed many tests, including biopsy, to find out the etiology of the rupture. These tests failed t o reveal any evidence of underlying diseases. It was speculated that his occupation, a fisherman, might be a possible predisposing condition because he had repeatedly dragged a heavy fishing net. The manifestations of a common carotid aneurysm can include progressive enlargement

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with rupture, local symptoms secondary to compression, distal cerebral embolization, and complete thrombosis with spontaneous remission of all symptom^.^"^ In this case, histologic examination of the wall of the aneurysm revealed only the adventitial layer, suggesting a pseudoaneurysm. Blood chemistry, serology, and clinical examination indicated neither atherosclerosis nor syphilis. The patient denied any previous operation or trauma, particularly on the head and neck. Although we could not determine the exact cause of rupture in this patient because of absence of the histologic examination of the carotid artery wall, there is a possibility that our patient had had a small aneurysm or a localized congenital defect which had not manifested any clinical symptoms, and the aneurysm or the defect was ruptured during Valsalva maneuver. Clinically false arterial aneurysms are seen as expanding pulsatile mass lesion^.^,^^,^^ Depending on the location and size, various manifestations, such as dysphagia, hoarseness, dyspnea, cranial neuropathy, Horner's s y n d r ~ m e , ~ , ~ ~ ~ headache, dizziness, tinnitus, facial pain, chillness, and visual disturbance may be present." Few cases of bleeding into the external auditory canal, the eustachian tube, or the oropharynx have been reported." The single pathognomonic sign is a systolic bruit heard over the area of the mass. The presence of both a thrill and palpable pulsation is a more variable oc~urrence.~ The patient suffered from a sudden expanding pulsatile mass and complained of hoarseness and mild dyspnea. With the support of the clinical signs and findings from CT, we had no difficulty in making the diagnosis of ruptured major vessel. The diagnosis is often confirmed on the basis of angiography, ultrasonography, and CT scan. Angiography is helpful for confirmation, for delineating the lesion and its vascular supply, and for ruling out the presence of associated vascular lesions, such as arteriovenous fistula^.^^^^ Pseudoaneurysms are diagnosed angiographically by delayed filling and slow emptying, residual contrast in the sac long after the arterial phase is over, and displacement of contiguous vessels.6 Ultrasonography is an accurate noninvasive method for the assessment of the size and configuration of aneurysms in the neck, the presence or absence of intraluminal or extraluminal thrombus, and the condition of the surrounding tissue^.^ A CT scan of the neck with contrast en-

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hancement is usually diagnostic of a carotid artery a n e u r y ~ m . ~ Treatment of these aneurysms varies and is largely determined by several factors including: anatomic extent of the aneurysm, etiology, adequacy of contralateral cerebral blood flow, and Because the presence or absence of infe~ti0n.l~ adequate stump pressure of the internal carotid artery is helpful in determining whether the continuity of the carotid system can be relatively safely sacrificed, it is important to evaluate the intracranial blood flow crossover, preoperatively. Arteriography alone is not reliable for determining the adequacy of the cross circulation. Oculoplethysmography (OPG) can be used for preoperative measurement of carotid stump pressure by ipsilateral compression of the common carotid artery. Occlusion tolerance test during angiography is one of the most reliable and practical methods to check the adequacy of the collateral circulation. As described in the case review, no neurologic deficit after balloon occlusion of the carotid artery indicates adequate collateral blood flow. We, however, recommend avoiding unnecessary ligation or sacrifice of the carotid artery because we have had two other patients whose MRI showed infarction of the basal ganglia in spite of favorable results of the occlusion tolerance test. In addition, the occlusion of the common carotid artery is expected to give more damage to the brain than the occlusion of the internal carotid artery, if present, the authors tried to reduce the duration of the vascular clamping. Surgical treatment of a false arterial aneurysm should be undertaken as soon as possible after the diagnosis is made to prevent the rupture or the development of a compartment syndrome or ne~r0pathy.l~ The possibility of distal cerebral embolization of the thrombus formed by slow turbulent blood flow is an another important reason for early surgical intervention. Sir Astley Cooper treated his first patient with a carotid aneurysm in 1808 by proximal ligation of the arterye4,I3Dimtza in 1952,l’ and Shea and Harrison in 1953 reported resection of an aneurysm of the carotid artery with end-toend The first prosthetic graft replacement for this lesion was accomplished by Beall and associates in 1959, using an internal shunt and a Dacron interposition graft. Primary resection of the carotid aneurysm with the reconstruction of the continuity of the blood flow by complete vascular closure or the interposition of

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a Dacron graft, saphenous vein, or autologous artery is now considered the treatment of c h ~ i c e . ~The , ~ defect ~ ’ ~ ~of the artery is usually small, and in selected cases it can be repaired by lateral sutures without graft replacement or permanent ligation.399Transvascular embolization of the extracranial carotid arterial tree also has numerous uses, excellent results, and negligible risk^.^,^^ Some aneurysms become smaller spontane0us1y.l~Heparin has been shown to be effective in preventing thrombosis and emboli in the terminal cerebral c i r ~ u l a t i o n . ~ ’ ~ A CT scan, ultrasonography, and angiography, which this patient underwent prior to operation, revealed a pseudoaneurysm originating from a rent of the common carotid artery just beneath the bifurcation with presence of thrombus and adequacy of contralateral cerebral blood flow. Surgical intervention disclosed a small, 5-mm long, longitudinal rent on the medial side of the common carotid artery, 20 mm proximal to the bifurcation. With temporary clamping of the common and internal carotid artery, it was possible to resect the false aneurysmal sac and to repair the arterial wall successfully by primary suture alone.

REFERENCES

1. Shumrick DA. Carotid artery rupture. Laryngoscope 1973;83:1051- 1061. 2. Leikensohn J, Milko D, Cotton R. Carotid artery rupture: management and prevention of delayed neurologic sequelae with low dose heparin. Arch Otolaryngol 1978;104:307-310, 3. Mogi G, Kado K. Spontaneous rupture of the common carotid artery. Arch Otolaryngol 1982;108525-527. 4. Katsantonis GP, Freidman WH, Keilmovitch I. Carotid artery aneurysm: a case report of a n unusual presentation. Otolaryngol Head Neck Surg 1983;91:303-306. 5. Calem WS. Traumatic (false) aneurysm of the terminal portion of the external carotid artery. A m J Surg 1963;106:522-524. 6. Jay J , Shapiro BM, Komisar A, Lawson W. Posttraumatic pseudoaneurysm of the extracranial middle meningeal artery. Arch Otolaryngol 1985;111:264- 266. 7. Ehrenfeld WK, Hays RJ. False aneurysm after carotid endarterectomy. Arch Surg 1972;104:288- 291. 8. Rich NM, Hobson RW, Collins GJ. Traumatic arteriovenous fistulas and false aneurysms: a review of 558 lesions. Surgery 1975;78:817-828. 9. Bole PV, Minda R, Purdy RT, e t al. Traumatic pseudoaneurysm: a review of 32 cases. J Trauma 1976;16:63-70. 10 McCollum CH, Wheeler WG, Noon GP, DeBaker ME. Aneurysm of the extracranial carotid artery: twenty-one years’ experience. A m J Surg 1979;137:196-200. 11 Rittenhouse EA, Radke HM, Sumner DS. Carotid artery aneurysm: review of the literature and report of a case with rupture into the oropharynx. Arch Surg 1972;105:786-789.

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12. Shunuzy T, Sakakura Y, Yamagiwa M, Hori M, Yuasa H, Murata M. Aneurysm of the extracranial carotid artery. Arch Otolalyngol 1986;112:203-206. 13. Sabiston DC, ed. Aneurysm of the carotic artery. In: Textbook of Surgery. Philadelphia: WB Saunders, 1981:1900- 1903. 14. Schwartz HC, Kendrick RW, Pogorel BS. False aneurysm of the maxillary artery: an unusual complication of closed facial trauma. Arch Otolaryngol 1983;109:616618.

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15. Busuttil RW, Davidson RK, Foley KT, Livesay JT, Barker WF. Selective management of extracranial carotid arterial aneurysms. A m J Surg 1980;140:85-91. 16. Raphael HA, Bernatz PE, Spittell JA, Ellis FH. Cervical carotid aneurysms: treatment by excision and restoration of arterial continuity. A m J Surg 1963;105:771-779. 17. Merland J J , Riche MC, Chiras J, Bories J. Therapeutic angiography in neuroradiology. Classical data, recent advances and perspectives. Neuroradiology 1981;21:111121.

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Spontaneous rupture of the common carotid artery: a case report.

Spontaneous rupture of the common carotid artery is an extremely rare vascular disorder in the head and neck region. Pseudoaneurysm can be formed by a...
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