Internal Carotid Artery Pseudoaneurysms in Children

A Diagnostic and Therapeutic Dilemma

Abstract

Aneurysms of the cervical part of the internal carotid artery in children are a rare presentation. Prompt and accurate diagnosis is the key to a successful outcome. Management ranges from observation to minimally invasive or open surgical procedures. A 9-year-old female child presented to us with an ill-defined, pulsatile left neck swelling with an intraoral bulge in the left tonsillar fossa. Diagnosis was made on the basis of high clinical suspicion, and digital subtraction angiography was utilized both for diagnosis and a therapeutic intervention. There was a marked reduction of the swelling in the postoperative period showing near-complete resolution in 1 week.

INTRODUCTION

Aneurysms of the extracranial part of the internal carotid artery (ICA) are a rare diagnosis[¹] in the regular outpatient visits in the department of otorhinolaryngology.

True aneurysms are a more common pathology in comparison to pseudoaneurysms.[²] Psuedoaneurysms are defined as focal blood collection in the arterial wall which has an intraluminal connection, presenting commonly as a swelling in the carotid triangle in the neck which is pulsatile, progressive in size, and associated with a bruit,[³] which can often be mistaken as an abscess due to a concomitant history of fever. If not diagnosed early, it can be a catastrophic disease for the patients in the event of sudden rupture of the pseudoaneurysm. High suspicion is the key to an early and accurate diagnosis of this entity.

Management can range from a conservative approach to minimally invasive and finally, to open surgical procedures. Conservative management with anticoagulants and antiplatelets can be considered in young asymptomatic patients, although they carry a high risk of failure and possible mortality.[^1,2]

Minimally invasive procedures such as stent placement with coiling of the aneurysm through struts, sac exclusion of aneurysm through the endovascular route have been described. Open repair includes ligation and excision with reconstruction using prosthesis material or venous grafts though with a higher chance of mortality and morbidity.[^4,5]

CASE REPORT

We report a case of a 9-year-old female child who presented in our outpatient department with complaints of swelling in the left side of the neck for 15 days and was associated with fever and dull pain over the swelling for the past 5 days. There was a history of associated coughing, probably attributed to the upper respiratory tract infection (URTI); she had suffered recently. There was no history of respiratory distress, dysphagia, or neurological complaints.

On examination, there was an ill-defined, soft, partially compressible, nontender pulsatile swelling in the left carotid triangle approximately 4 cm × 3 cm. There was bruit on auscultation. Intraoral examination was suggestive of a diffuse bulge in the left tonsillar fossa [Figure 1]. An ultrasound of the neck was done which showed a collection measuring 56 mm × 22 mm × 28 mm having a volume of 2030 mm with aneurysmal dilatation of the external carotid artery or one of its branches measuring 27 mm × 17 mm with flow seen within it.

Figure 1: Left tonsillar bulge (white arrow)

A radiological consultation was taken, and a diagnostic DSA was done, confirming a pseudoaneurysm of the left distal cervical ICA [Figures 2 and 3].

Figure 2: Left ICA pseudoaneurysm (white arrow). ICA: Internal carotid artery

Figure 3: Pseudoaneurysm of the left distal cervical internal carotid artery (white arrow)

General examination and examination of other systems were within normal limits. There was no recordable fever at presentation. Therapeutic intervention was done using coils for occlusion of the left ICA cervical segment and trapping of the aneurysm. Post coiling run showed complete obliteration of the aneurysm with normal preserved collateral flow across the anterior communicating and posterior communicating arteries[Figure 4].

Figure 4: Near complete obliteration of the aneurysm with normal preserved collateral flow across anterior communicating and posterior communicating artery (white arrow)

There was no complication encountered after the endovascular coiling of the aneurysm, and the patient was kept on IV heparin infusion 200 IU/h for 12 h. The patient was discharged on the postoperative day 3 with blood pressure of 120/80, pulse rate of 84/min, and respiratory rate of 24/min and was afebrile, with the intraoral bulge and neck swelling showing a significant reduction in size. Follow-up visit after 1 week showed complete resolution of the neck swelling and the intraoral bulge of the left tonsillar fossa [Figure 5].

Figure 5: Obliteration of left tonsillar bulge. White arrow denotes resolution of tonsillar bulge treatment

DISCUSSION

The causes of ICA pseudoaneurysm are trauma, iatrogenic, and infection, particularly in the pediatric population. Other predisposing factors are previous radiotherapy, connective tissue disorders, or the spread of nearby infection to the arterial wall.[^6-8] In our case, there were signs and symptoms of focal infection with a history of fever and painful neck swelling following URTI. There was no history of prior surgical intervention or any other predisposing risk factors, although there are chances of spontaneous hematomas in the neck.[⁹]

Symptoms may range from a majority being asymptomatic (30%60%).[¹⁰] to neurological symptoms such as Horner’s syndrome or depending on the cranial nerve involvement. They may rupture, resulting in life-threatening hemorrhage. Apart from the risk of hemorrhage, there is a chance of thrombosis and embolization to cause cerebral ischemia followed by neurological complications. In our case, the child had a neck swelling with the intraoral bulge in the left tonsillar area.

Diagnosis is made based on a high clinical suspicion and on radiology, with DSA being utilized both as a tool of diagnosis and for intervention. Other diagnostic options include computed tomography and magnetic resonance angiography. Our case underwent an ultrasound and contrast-enhanced computed tomography to T4 followed by DSA scan both as a diagnostic and a therapeutic modality bronchiolitis obliterans syndrome. Doppler may have difficulty in diagnosing thrombosed aneurysm with respect to DSA, which is the gold standard.

At present, endovascular techniques have become more popular than open surgical ligation.[¹¹] Open surgical procedures have a higher chance of neurological damage, whereas the risk of embolization and a cerebrovascular accident is higher in endovascular techniques.[¹²] Overall, it is safe to say that the endovascular approach is less invasive with a lower chance of complications[^13,14] as compared to the open surgical approach.

CONCLUSION

Pseudoaneurysms of the cervical part of the ICA are a rare clinical diagnosis and should not be mistaken for an abscess. Immediate treatment is necessary to decrease the chances of stroke and hemorrhage and subsequent mortality. Management is now preferred through the endovascular technique on account of lesser complication rates and high success rates.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.