Clinical Radiology (1991) 43, 162 165
Extracranial Carotid Artery Aneurysms following Accidental Injury: Ten Years Experience S. S H A R M A , M. R A J A N I , N. M I S H R A * , A. S A M P A T H K U M A R ~ and K. S. IYER]" Departments o f Cardiovascular and *Neuro-radiology, ~fCardiothoracic and Vascular Surgery, C N Centre, All India Institute o f Medical Sciences, N e w Delhi, India Extracranial carotid artery aneurysms secondary to accidental injury are rare. We have seen eight lesions of this type in the last 10 years. The aneurysm was produced by blunt trauma in four patients, penetrating shrapnel injury in two, stabbing and electrical injury in one each. The left side was involved in seven patients. The internal and common carotid artery were each involved in four patients and the lesion was unilocular in five. These lesions often produce non-specific symptoms and may mimic neoplastic or inflammatory masses: a mistaken diagnosis of tonsillar abscess in one patient resulted in incision and drainage before an intravenous digital subtraction angiogram (IV-DSA) correctly identified the abnormality. IV-DSA is ideal for pre-operative assessment of these patients. Awareness of these lesions is essential since definitive surgical repair is possible. All patients in the present study underwent successful surgical repair. Sharma, S., Rajani, M., Mishra, N., Sampathkumar, A. & Iyer, K. S. (1991). Clinical Radiology 43, 162 165. Extracranial Carotid Artery Aneurysms following Accidental Injury: Ten Years Experience
Extracranial carotid artery aneurysms are distinctly u n c o m m o n (Winslow, 1926; Shipley et al., 1937; K a u p p et al., 1972; Rhodes et al., 1976; Ameli et al., 1983; Painter et al., 1985; Knight et al., 1988) and those secondary to accidental trauma are rare (Salmon and Blatt, 1968; Robinson and Floote, 1974; Dragon and Strauch, 1981; Brown and DeBakey, 1982; Malin and Becker, 1985; Welling and Kakkaseril, 1985). Schechter (1979) analysed 853 extracranial carotid aneurysms in 820 persons recorded in the literature between 1967 and 1977; nontraumatic aneurysms were more c o m m o n (62.4%) and usually involved the internal carotid artery. They were bilateral in 33 cases (4%) and were then usually atherosclerotic in origin. Traumatic aneurysms were less frequent, usually affecting the c o m m o n carotid artery. Most post-traumatic aneurysms are caused by surgical trauma (McCollum et al., 1979; Mokri et al., 1982; Ameli et al_, 1983; Graver and Mulcore, 1986). The rarity of post-traumatic aneurysms following accidental injury can be assessed by the fact that in approximately 2500 cases of arterial injury seen during World W a r II, only 13 aneurysms of the carotid arteries were reported (Elkin and Shumaker, 1955). Beall and his colleagues (1962) performed 2300 operations on aneurysms of the whole extracranial arterial system; of seven involving the extracranial carotid arteries, only one was traumatic, and this was iatrogenic. Krupski et al. (1983) reported 22 extracranial carotid artery aneurysms in 21 patients: none was secondary to non-surgical trauma. Extracranial carotid artery aneurysms are interesting because firstly, in contrast with the waning frequency of many peripheral aneurysms, their incidence appears to be on the increase (Schechter, 1979), and secondly, they are frequently misdiagnosed and mismanaged due to the nonspecificity of the symptoms and signs. In view of the grave clinical implications of most extracranial carotid artery aneurysms, p r o m p t pre-operative diagnosis is highly desirable. Correspondence to: Dr Sanjiv Sharma, Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India.
We describe eight cases seen in the last decade at our Centre. The place of intravenous digital subtraction angiography (IV-DSA) in the diagnostic assessment of these patients is discussed. M E T H O D S AND R E S U L T S Over a period of 10 years, we have seen eight patients (five males; age range 12 to 45 years; mean age 25.6 years) with post-traumatic aneurysms of the extracranial carotid arteries following blunt or penetrating trauma to the neck. The nature of the injuries is summarized in Table 1. Six patients underwent conventional filmscreen angiography via transfemoral catheter, in the other two cases IV-DSA was carried out via right atrial, small-volume (25 ml), bolus injections delivered through a 5 French highfiow pigtail catheter introduced by percutaneous puncture of a right arm vein. The angiograms were obtained in right and left anterior oblique and anteroposterior projections. All patients subsequently underwent surgery. The angiographic and surgical findings are summarized in Table 1. The aneurysms arose from c o m m o n carotid artery in four patients, and from the internal carotid artery in another four. The left sided vessel was involved in seven of eight patients. All the aneurysms were saccular: five were unilocular and three were multilocular. At surgery, excision of the sac, either total or subtotal, with repair of the tear in the wall of the artery was carried out in seven patients and an end-to-side saphenous vein graft was placed in the eighth. There was no operative mortality and all patients had an uneventful postoperative recovery. DISCUSSION Most traumatic carotid aneurysms are the aftermath of penetrating wounds. Materials incriminated include projectiles, weapons, fishbones, safety pins, needles (through
POST-TRAUMATICCAROTID ARTERY ANEURYSMS
163
Table 1 - Angiographic surgical correlation
Case Age no. (years)
Sex
Nature of injury
Angiography
Surgery
1
45
M
Largepseudoaneurysm in relation to left common Excision of sac and suturing of the arterial rent carotid artery
2
28
M
3
18
M
Penetrating neck injury by shrapnel in a stone quarry Penetrating neck injury by shrapnel in a stone quarry (Fig. 1) Blunt trauma to the neck
4
26
F
5
30
F
6
26
M
7
30
F
8
12
M
Largepseudoaneurysm in relation to the left common carotid artery (Fig. 1)
Pseudoaneurysm in relation to the left internal carotid artery soon after its origin (Fig. 2) Blunt trauma to the neck Largepseudoaneurysm in relation to the right internal carotid artery soon after its origin Blunt trauma to the neck Leftinternal carotid artery aneurysm soon after its origin Stab injury to the n e c k Largepseudoaneurysm in relation to the left common carotid artery (Fig. 3) Blunt injury to the neck Left saecular aneurysm of left internal carotid artery soon after its bifurcation Electricalinjury to the Multiloculated aneurysm of left common carotid neck artery
Fig 1 - IV-DSA of neck vessels in antero-posterior view showing an aneurysmin relation to left common carotid artery (arrows). A foreign body (shrapnel), is also seen embedded in the vicinity (arrowhead).
' m a i n l i n i n g ' narcotics in the neck), nitric acid p o u r e d into the ear, a n d slivers of metal or w o o d (Schechter, 1979). In our series electrical injury a n d chips of iron (in stone quarry workers) resulted in t r a u m a t i c a n e u r y s m formation_ B l u n t t r a u m a such as extreme strain while coughing or playing wind i n s t r u m e n t s , accidental or criminal b l u n t
Excision of sac with suturing of the arterial rent Excision of sac with suturing of the arterial rent Excision of sac and end-to-side saphenous vein by-pass graft Excision of sac with repair of rent Excision of sac with repair of rent Excision of sac with repair of rent Excision of sac with repair of rent
injuries to the head, deceleration accidents and irradiation of the neck leading to a n e u r y s m f o r m a t i o n have also been described as causes (Bole et al., 1975; Schechter, 1979). A l m o s t all p o s t - t r a u m a t i c aneurysms follow transm u r a l arterial disruption, from penetrating or b l u n t injury. A periarterial h a e m a t o m a is c o n t a i n e d by contiguous structures, or extravasates more widely into the soft tissues. The periphery o f the pulsating h a e m a t o m a then hardens, with f o r m a t i o n of collagen, while its central matrix cavitates and liquefies, resulting in a pseudoa n e u r y s m with n o vestige of regular arterial coats ( R o b i n s o n a n d Floote, 1974; Schechter, 1979). A n e u r y s m s caused by p e n e t r a t i n g t r a u m a are usually saccular. N o n - p e n e t r a t i n g t r a u m a m a y produce fusiform or saccular aneurysms, d e p e n d i n g u p o n the extent of devitalization a n d when the injury causes rucking up or dissection of the e n d o t h e l i u m . W h e n only a small p o r t i o n of the artery is aneurysmal, the rest of the vessel often becomes elongated a n d tortuous; this is particularly true with saccular aneurysms, because of the non-circumferential m u r a l involvement. K i n k i n g of the parent artery due to e l o n g a t i o n and tortuosity can exacerbate hindrance to blood flow by the a n e u r y s m itself (Hardin, 1961; Alexander et al., 1966). The clinical m a n i f e s t a t i o n s of these aneurysms vary according to their size a n d location, a n d are well docum e n t e d (Canascal et al., 1978; M o k r i et al., 1982; D a m m e et al., 1988; K n i g h t et al., 1988). It is worth emphasizing that these can mimic tonsillar abscesses and, as in our series, have occasionally been incised with catastrophic consequences (Winslow, 1926; Shipley et al., 1937; M o k r i et al., 1982). Plain films of the neck m a y show evidence of calcification in the aneurysm. A n g i o g r a p h y is essential for establishing the diagnosis a n d p l a n n i n g management_ The radiological features have been previously reported (Margolis et al., 1972). W e used I V - D S A as the initial investigation in two patients, with good results. It would appear ideal for studying these patients since p u n c t u r e a n d even catheterization of the a b n o r m a l vessel are
164
CLINICAL RADIOLOGY
¸
(a)
(h)
Fig. 3 Selective left carotid angiogram in the anteroposterior (a) and left oblique (b) views showing an aneurysm in relation to the left common carotid artery (arrow). There is a thrombus in the aneurysmal sac (arrowhead).
(~)
t h e r e b y a v o i d e d . Similarly, it c a n be useful for posto p e r a t i v e f o l l o w u p o f these p a t i e n t s . T r e a t m e n t is r e q u i r e d to p r e v e n t p o t e n t i a l l y lethal c o m p l i c a t i o n s . S u r g e r y is p r e f e r r e d a n d r e s e c t i o n o f the a n e u r y s m w i t h r e s t o r a t i o n o f arterial c o n t i n u i t y is the surgical p r o c e d u r e o f choice ( M c C o l l u m et al., 1979). M a n y w o r k e r s r e c o m m e n d resection w i t h p r i m a r y endt o - e n d a n a s t o m o s i s ( K a u p p et al., 1972; R h o d e s et al., 1976). P o s t - t r a u m a t i c a n e u r y s m s o f the e x t r a c r a n i a l c a r o t i d arteries are rare, b u t a w a r e n e s s o f the p o s s i b i l i t y is essential for p r o m p t a n d a c c u r a t e d i a g n o s i s a n d p l a n n i n g of optimal management. IV-DSA provides instantan e o u s , d i a g n o s t i c a l l y a d e q u a t e arterial i m a g e s a n d a p p e a r s ideally suited for pre- a n d p o s t - o p e r a t i v e investigation.
REFERENCES
Ameli, FM, Provan, KL & Keuchler, PM (1983). Unusual aneurysms of the extracranial carotid artery. Journal of Cardiovascular Surgery, 24, 69-73. Alexander, E, Wigser, SM & Davis, CH (1966). Bilateral extracranial aneurysms of the internal carotid artery. Case report. Journal of Neurosurgery, 25, 437 442. Beall, AC, Crawford, ES, Cooley, DA & DeBakey, ME (1962). Extracranial aneurysms of the carotid artery. Postgraduate Medicine, 32, 93-102. Bole, PV, Hintz, G, Chander, P, Chan, YS & Clauss, RH (1975). Bilateral carotid aneurysms secondary to radiation therapy. Annals of Surgery, 181, 888-892. Brown, M & DeBekay, M (1982). Carotid artery injuries. American Journal of Surgery, 144, 748 753. Canascal, L, Mashiah, A & Charlesworth, D (1978). Aneurysm of the extracranial carotid arteries. British Journal of Surgery, 65, 590-592. Damme, HV, Leconte, M, DeKoster G & Limet, R (1988). Pseudoaneurysm of the high extracranial internal carotid artery: case report and literature review. Vascular Surgery, 22, 354-360. Dragon, R & Strauch, G (1981). Blunt injuries to the carotid and vertebral arteries. American Journal of Surgery, 141, 497-500. Elkin, DC & Shumaker, HB (1956). Surgery in Worm War IL United States Army, Office of the Surgeon General, Department of Army, Washington, DC.
(b)
Fig. 2 - Left carotid angiogram in the anteroposterior (a) and left oblique (b) views showing a large saccular aneurysm at the origin of left internal carotid artery.
POST-TRAUMATIC CAROTID ARTERY ANEURYSMS Graver, LM & Mulcare, RJ (1986). Pseudoaneurysm after carotid endarterectomy. Journal of Cardiovascular Surgery, 27, 294-296. Hardin, CA (1961). Carotid body tumours and aneurysms. Angiology, 12, 597-60O. Kaupp, HA, Haid, SP, Jurayi, MN, Bergan, JJ & Trippel, OH (1972). Aneurysms of the extracraniaI carotid artery. Surgery, 72, 946-951. Knight, GC, Hallman, GL, Reul, GJ, Ott, DA & Cooley, DA (1988). Surgical management of extracranial carotid artery aneurysms: report of 17 cases. Texas Heart Institute Journal, 15, 91 97. Krupski, WC, Effeney, DJ, Ehrenfeld, WK & Stoney, RJ (1983). Aneurysms of the carotid arteries. Australia New Zealand Journal of Surgery, 53, 521 525. Malin, JP & Becker, H. (1985). Bilateral traumatic extracranial aneurysm of the internal carotid artery with delayed brain infarction. Journal of Neurology, 232, 314-317. Margolis, MT, Stein, RL & Newton, TH (1972). Extracranial aneurysms of the internal carotid artery. Neuroradiology, 4, 78 89. McCollum, CH, Wheeler, WG, Noon, GP & DeBakey, ME (1979): Aneurysm of extracranial carotid arteries 21 years' experience. American Journal of Surgery, 137, 196-200. Mokri, B, Pieogras, DG, Sundt, TM & Pearson, BW (1982). Extracranial internal carotid artery aneurysms. Mayo Clinic Proceedings, 57, 310-32l.
165
Painter, TA, Hertzer, NR, Bewen, EG & O'Hara, PJ (1985). Extracranial carotid aneurysms: report of six cases and review of literature. Journal of Vascular Surgery, 2, 312 318. Rhodes, EL, Stanley, JC & Hoffman, GL (1976). Aneurysm of the extracranial carotid arteries. Archives of Surgery, 111, 339 343. Robinson, NA & Floote, T (1974). Traumatic aneurysrns of the carotid arteries. American Surgeon, 40, 121-124. Salmon, JH & Blatt, EJ (1968). Aneurysms of the internal carotid artery due to closed trauma. Journal of Thoracic and Cardiovascular Surgery, 56, 28 32. Schechter, DG (1979). Cervical carotid aneurysms. New York State Journal of Medicine, 79, 892 901. Shipley, AM, Winslow, N & Walker, WW (1937). Aneurysm in the cervical portion of the internal carotid artery: an analytical study of the cases recorded in the literature between August 1, 1925 and July 31, 1936: report of two cases. Annals of Surgery, 195, 673-699. Welling, R & Kakkaseril J (1985) Pseudoaneurysm of cervical internal carotid artery secondary to blunt trauma. Journal of Trauma, 25, 1108 1110. Winslow, IV (1926). Extracranial aneurysms of internal carotid artery. Archives of Surgery, 13, 689 729.
Extracranial Carotid Artery Aneurysms following Accidental Injury: Ten Years Experience S. S H A R M A , M. R A J A N I , N. M I S H R A * , A. S A M P A T H K U M A R ~ and K. S. IYER]" Departments o f Cardiovascular and *Neuro-radiology, ~fCardiothoracic and Vascular Surgery, C N Centre, All India Institute o f Medical Sciences, N e w Delhi, India Extracranial carotid artery aneurysms secondary to accidental injury are rare. We have seen eight lesions of this type in the last 10 years. The aneurysm was produced by blunt trauma in four patients, penetrating shrapnel injury in two, stabbing and electrical injury in one each. The left side was involved in seven patients. The internal and common carotid artery were each involved in four patients and the lesion was unilocular in five. These lesions often produce non-specific symptoms and may mimic neoplastic or inflammatory masses: a mistaken diagnosis of tonsillar abscess in one patient resulted in incision and drainage before an intravenous digital subtraction angiogram (IV-DSA) correctly identified the abnormality. IV-DSA is ideal for pre-operative assessment of these patients. Awareness of these lesions is essential since definitive surgical repair is possible. All patients in the present study underwent successful surgical repair. Sharma, S., Rajani, M., Mishra, N., Sampathkumar, A. & Iyer, K. S. (1991). Clinical Radiology 43, 162 165. Extracranial Carotid Artery Aneurysms following Accidental Injury: Ten Years Experience
Extracranial carotid artery aneurysms are distinctly u n c o m m o n (Winslow, 1926; Shipley et al., 1937; K a u p p et al., 1972; Rhodes et al., 1976; Ameli et al., 1983; Painter et al., 1985; Knight et al., 1988) and those secondary to accidental trauma are rare (Salmon and Blatt, 1968; Robinson and Floote, 1974; Dragon and Strauch, 1981; Brown and DeBakey, 1982; Malin and Becker, 1985; Welling and Kakkaseril, 1985). Schechter (1979) analysed 853 extracranial carotid aneurysms in 820 persons recorded in the literature between 1967 and 1977; nontraumatic aneurysms were more c o m m o n (62.4%) and usually involved the internal carotid artery. They were bilateral in 33 cases (4%) and were then usually atherosclerotic in origin. Traumatic aneurysms were less frequent, usually affecting the c o m m o n carotid artery. Most post-traumatic aneurysms are caused by surgical trauma (McCollum et al., 1979; Mokri et al., 1982; Ameli et al_, 1983; Graver and Mulcore, 1986). The rarity of post-traumatic aneurysms following accidental injury can be assessed by the fact that in approximately 2500 cases of arterial injury seen during World W a r II, only 13 aneurysms of the carotid arteries were reported (Elkin and Shumaker, 1955). Beall and his colleagues (1962) performed 2300 operations on aneurysms of the whole extracranial arterial system; of seven involving the extracranial carotid arteries, only one was traumatic, and this was iatrogenic. Krupski et al. (1983) reported 22 extracranial carotid artery aneurysms in 21 patients: none was secondary to non-surgical trauma. Extracranial carotid artery aneurysms are interesting because firstly, in contrast with the waning frequency of many peripheral aneurysms, their incidence appears to be on the increase (Schechter, 1979), and secondly, they are frequently misdiagnosed and mismanaged due to the nonspecificity of the symptoms and signs. In view of the grave clinical implications of most extracranial carotid artery aneurysms, p r o m p t pre-operative diagnosis is highly desirable. Correspondence to: Dr Sanjiv Sharma, Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India.
We describe eight cases seen in the last decade at our Centre. The place of intravenous digital subtraction angiography (IV-DSA) in the diagnostic assessment of these patients is discussed. M E T H O D S AND R E S U L T S Over a period of 10 years, we have seen eight patients (five males; age range 12 to 45 years; mean age 25.6 years) with post-traumatic aneurysms of the extracranial carotid arteries following blunt or penetrating trauma to the neck. The nature of the injuries is summarized in Table 1. Six patients underwent conventional filmscreen angiography via transfemoral catheter, in the other two cases IV-DSA was carried out via right atrial, small-volume (25 ml), bolus injections delivered through a 5 French highfiow pigtail catheter introduced by percutaneous puncture of a right arm vein. The angiograms were obtained in right and left anterior oblique and anteroposterior projections. All patients subsequently underwent surgery. The angiographic and surgical findings are summarized in Table 1. The aneurysms arose from c o m m o n carotid artery in four patients, and from the internal carotid artery in another four. The left sided vessel was involved in seven of eight patients. All the aneurysms were saccular: five were unilocular and three were multilocular. At surgery, excision of the sac, either total or subtotal, with repair of the tear in the wall of the artery was carried out in seven patients and an end-to-side saphenous vein graft was placed in the eighth. There was no operative mortality and all patients had an uneventful postoperative recovery. DISCUSSION Most traumatic carotid aneurysms are the aftermath of penetrating wounds. Materials incriminated include projectiles, weapons, fishbones, safety pins, needles (through
POST-TRAUMATICCAROTID ARTERY ANEURYSMS
163
Table 1 - Angiographic surgical correlation
Case Age no. (years)
Sex
Nature of injury
Angiography
Surgery
1
45
M
Largepseudoaneurysm in relation to left common Excision of sac and suturing of the arterial rent carotid artery
2
28
M
3
18
M
Penetrating neck injury by shrapnel in a stone quarry Penetrating neck injury by shrapnel in a stone quarry (Fig. 1) Blunt trauma to the neck
4
26
F
5
30
F
6
26
M
7
30
F
8
12
M
Largepseudoaneurysm in relation to the left common carotid artery (Fig. 1)
Pseudoaneurysm in relation to the left internal carotid artery soon after its origin (Fig. 2) Blunt trauma to the neck Largepseudoaneurysm in relation to the right internal carotid artery soon after its origin Blunt trauma to the neck Leftinternal carotid artery aneurysm soon after its origin Stab injury to the n e c k Largepseudoaneurysm in relation to the left common carotid artery (Fig. 3) Blunt injury to the neck Left saecular aneurysm of left internal carotid artery soon after its bifurcation Electricalinjury to the Multiloculated aneurysm of left common carotid neck artery
Fig 1 - IV-DSA of neck vessels in antero-posterior view showing an aneurysmin relation to left common carotid artery (arrows). A foreign body (shrapnel), is also seen embedded in the vicinity (arrowhead).
' m a i n l i n i n g ' narcotics in the neck), nitric acid p o u r e d into the ear, a n d slivers of metal or w o o d (Schechter, 1979). In our series electrical injury a n d chips of iron (in stone quarry workers) resulted in t r a u m a t i c a n e u r y s m formation_ B l u n t t r a u m a such as extreme strain while coughing or playing wind i n s t r u m e n t s , accidental or criminal b l u n t
Excision of sac with suturing of the arterial rent Excision of sac with suturing of the arterial rent Excision of sac and end-to-side saphenous vein by-pass graft Excision of sac with repair of rent Excision of sac with repair of rent Excision of sac with repair of rent Excision of sac with repair of rent
injuries to the head, deceleration accidents and irradiation of the neck leading to a n e u r y s m f o r m a t i o n have also been described as causes (Bole et al., 1975; Schechter, 1979). A l m o s t all p o s t - t r a u m a t i c aneurysms follow transm u r a l arterial disruption, from penetrating or b l u n t injury. A periarterial h a e m a t o m a is c o n t a i n e d by contiguous structures, or extravasates more widely into the soft tissues. The periphery o f the pulsating h a e m a t o m a then hardens, with f o r m a t i o n of collagen, while its central matrix cavitates and liquefies, resulting in a pseudoa n e u r y s m with n o vestige of regular arterial coats ( R o b i n s o n a n d Floote, 1974; Schechter, 1979). A n e u r y s m s caused by p e n e t r a t i n g t r a u m a are usually saccular. N o n - p e n e t r a t i n g t r a u m a m a y produce fusiform or saccular aneurysms, d e p e n d i n g u p o n the extent of devitalization a n d when the injury causes rucking up or dissection of the e n d o t h e l i u m . W h e n only a small p o r t i o n of the artery is aneurysmal, the rest of the vessel often becomes elongated a n d tortuous; this is particularly true with saccular aneurysms, because of the non-circumferential m u r a l involvement. K i n k i n g of the parent artery due to e l o n g a t i o n and tortuosity can exacerbate hindrance to blood flow by the a n e u r y s m itself (Hardin, 1961; Alexander et al., 1966). The clinical m a n i f e s t a t i o n s of these aneurysms vary according to their size a n d location, a n d are well docum e n t e d (Canascal et al., 1978; M o k r i et al., 1982; D a m m e et al., 1988; K n i g h t et al., 1988). It is worth emphasizing that these can mimic tonsillar abscesses and, as in our series, have occasionally been incised with catastrophic consequences (Winslow, 1926; Shipley et al., 1937; M o k r i et al., 1982). Plain films of the neck m a y show evidence of calcification in the aneurysm. A n g i o g r a p h y is essential for establishing the diagnosis a n d p l a n n i n g management_ The radiological features have been previously reported (Margolis et al., 1972). W e used I V - D S A as the initial investigation in two patients, with good results. It would appear ideal for studying these patients since p u n c t u r e a n d even catheterization of the a b n o r m a l vessel are
164
CLINICAL RADIOLOGY
¸
(a)
(h)
Fig. 3 Selective left carotid angiogram in the anteroposterior (a) and left oblique (b) views showing an aneurysm in relation to the left common carotid artery (arrow). There is a thrombus in the aneurysmal sac (arrowhead).
(~)
t h e r e b y a v o i d e d . Similarly, it c a n be useful for posto p e r a t i v e f o l l o w u p o f these p a t i e n t s . T r e a t m e n t is r e q u i r e d to p r e v e n t p o t e n t i a l l y lethal c o m p l i c a t i o n s . S u r g e r y is p r e f e r r e d a n d r e s e c t i o n o f the a n e u r y s m w i t h r e s t o r a t i o n o f arterial c o n t i n u i t y is the surgical p r o c e d u r e o f choice ( M c C o l l u m et al., 1979). M a n y w o r k e r s r e c o m m e n d resection w i t h p r i m a r y endt o - e n d a n a s t o m o s i s ( K a u p p et al., 1972; R h o d e s et al., 1976). P o s t - t r a u m a t i c a n e u r y s m s o f the e x t r a c r a n i a l c a r o t i d arteries are rare, b u t a w a r e n e s s o f the p o s s i b i l i t y is essential for p r o m p t a n d a c c u r a t e d i a g n o s i s a n d p l a n n i n g of optimal management. IV-DSA provides instantan e o u s , d i a g n o s t i c a l l y a d e q u a t e arterial i m a g e s a n d a p p e a r s ideally suited for pre- a n d p o s t - o p e r a t i v e investigation.
REFERENCES
Ameli, FM, Provan, KL & Keuchler, PM (1983). Unusual aneurysms of the extracranial carotid artery. Journal of Cardiovascular Surgery, 24, 69-73. Alexander, E, Wigser, SM & Davis, CH (1966). Bilateral extracranial aneurysms of the internal carotid artery. Case report. Journal of Neurosurgery, 25, 437 442. Beall, AC, Crawford, ES, Cooley, DA & DeBakey, ME (1962). Extracranial aneurysms of the carotid artery. Postgraduate Medicine, 32, 93-102. Bole, PV, Hintz, G, Chander, P, Chan, YS & Clauss, RH (1975). Bilateral carotid aneurysms secondary to radiation therapy. Annals of Surgery, 181, 888-892. Brown, M & DeBekay, M (1982). Carotid artery injuries. American Journal of Surgery, 144, 748 753. Canascal, L, Mashiah, A & Charlesworth, D (1978). Aneurysm of the extracranial carotid arteries. British Journal of Surgery, 65, 590-592. Damme, HV, Leconte, M, DeKoster G & Limet, R (1988). Pseudoaneurysm of the high extracranial internal carotid artery: case report and literature review. Vascular Surgery, 22, 354-360. Dragon, R & Strauch, G (1981). Blunt injuries to the carotid and vertebral arteries. American Journal of Surgery, 141, 497-500. Elkin, DC & Shumaker, HB (1956). Surgery in Worm War IL United States Army, Office of the Surgeon General, Department of Army, Washington, DC.
(b)
Fig. 2 - Left carotid angiogram in the anteroposterior (a) and left oblique (b) views showing a large saccular aneurysm at the origin of left internal carotid artery.
POST-TRAUMATIC CAROTID ARTERY ANEURYSMS Graver, LM & Mulcare, RJ (1986). Pseudoaneurysm after carotid endarterectomy. Journal of Cardiovascular Surgery, 27, 294-296. Hardin, CA (1961). Carotid body tumours and aneurysms. Angiology, 12, 597-60O. Kaupp, HA, Haid, SP, Jurayi, MN, Bergan, JJ & Trippel, OH (1972). Aneurysms of the extracraniaI carotid artery. Surgery, 72, 946-951. Knight, GC, Hallman, GL, Reul, GJ, Ott, DA & Cooley, DA (1988). Surgical management of extracranial carotid artery aneurysms: report of 17 cases. Texas Heart Institute Journal, 15, 91 97. Krupski, WC, Effeney, DJ, Ehrenfeld, WK & Stoney, RJ (1983). Aneurysms of the carotid arteries. Australia New Zealand Journal of Surgery, 53, 521 525. Malin, JP & Becker, H. (1985). Bilateral traumatic extracranial aneurysm of the internal carotid artery with delayed brain infarction. Journal of Neurology, 232, 314-317. Margolis, MT, Stein, RL & Newton, TH (1972). Extracranial aneurysms of the internal carotid artery. Neuroradiology, 4, 78 89. McCollum, CH, Wheeler, WG, Noon, GP & DeBakey, ME (1979): Aneurysm of extracranial carotid arteries 21 years' experience. American Journal of Surgery, 137, 196-200. Mokri, B, Pieogras, DG, Sundt, TM & Pearson, BW (1982). Extracranial internal carotid artery aneurysms. Mayo Clinic Proceedings, 57, 310-32l.
165
Painter, TA, Hertzer, NR, Bewen, EG & O'Hara, PJ (1985). Extracranial carotid aneurysms: report of six cases and review of literature. Journal of Vascular Surgery, 2, 312 318. Rhodes, EL, Stanley, JC & Hoffman, GL (1976). Aneurysm of the extracranial carotid arteries. Archives of Surgery, 111, 339 343. Robinson, NA & Floote, T (1974). Traumatic aneurysrns of the carotid arteries. American Surgeon, 40, 121-124. Salmon, JH & Blatt, EJ (1968). Aneurysms of the internal carotid artery due to closed trauma. Journal of Thoracic and Cardiovascular Surgery, 56, 28 32. Schechter, DG (1979). Cervical carotid aneurysms. New York State Journal of Medicine, 79, 892 901. Shipley, AM, Winslow, N & Walker, WW (1937). Aneurysm in the cervical portion of the internal carotid artery: an analytical study of the cases recorded in the literature between August 1, 1925 and July 31, 1936: report of two cases. Annals of Surgery, 195, 673-699. Welling, R & Kakkaseril J (1985) Pseudoaneurysm of cervical internal carotid artery secondary to blunt trauma. Journal of Trauma, 25, 1108 1110. Winslow, IV (1926). Extracranial aneurysms of internal carotid artery. Archives of Surgery, 13, 689 729.
