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Carotid artery dissection is a rare entity, and most cases are attributable to causative factors, which include trauma and local malignancy. The vast majority of dissections present with cerebral infarct; those few that present with local mass effect and respiratory compromise may deteriorate rapidly, requiring urgent resuscitation and consideration of endotracheal intubation, which is often dangerous and/or impossible. The case of a spontaneous internal carotid artery dissection in an otherwise healthy young man, leading to gross mass effect and eventual fatal airway obstruction, is presented here. The need for a high index of suspicion for cervical vascular injury in cases of neck injury (even trivial), known head and neck malignancy/irradiation, or coagulopathy is highlighted. Patients presenting with unilateral neck swelling and symptoms related to mass effect must be assumed to have progressive airway obstruction, and difficult intubation should be anticipated.
Carotid artery dissection is a rare entity, and most cases are attributable to a causative factor. We present the case of a spontaneous internal carotid artery dissection in an otherwise healthy young man, leading to gross mass effect and eventual fatal airway obstruction.
A 41‐year‐old, previously healthy Afro‐Caribbean man presented to the emergency department with a 4 h history of mild neck discomfort associated with swelling in the left side of the neck. There was no history of trauma, foreign body ingestion, tuberculosis or anticoagulation. At 30 min before arrival he had begun to experience some difficulty swallowing, with no change in voice quality, and shortly after arrival complained of difficulty breathing and experienced haemoptysis of approximately 50 ml fresh blood.
Palpation of the neck showed grossly abnormal anatomy: marked shift of the trachea, cricoid and thyroid cartilages towards the right, and a large, ill‐defined, soft, non‐pulsatile mass in the left side of the neck. Percussion and auscultation of the chest were found to be normal. A plain radiograph of the chest (fig 11)) showed significant shift of midline neck structures to the right, an irregular and compressed trachea, and considerable soft‐tissue swelling in the neck bilaterally. Objective measurements indicated good arterial oxygenation and haemodynamic stability. Bedside ultrasonography was inconclusive.
Shortly thereafter, the patient experienced massive haemoptysis, with progressive haemodynamic instability. Despite initial needle cricothyroidotomy and difficult subsequent endotracheal intubation, along with aggressive volume replacement with crystalloids and blood, he developed respiratory trouble and subsequently cardiac arrest. Prolonged attempts to resuscitate were unsuccessful.
Primary autopsy showed intact vasculature in the neck and upper mediastinum, and failed to illustrate a cause for the patient's death. There was extensive haemorrhage into the tissue at the left side of the neck; the bronchi and lungs contained blood; and a large amount of fresh blood was present in the stomach. After fixation, sectioning showed dissection at the origin of the internal carotid artery, immediately beyond its bifurcation. The cause of death was deemed to be pharyngeal haemorrhage secondary to dissection of the bifurcation of the internal carotid artery.
Carotid artery dissections (and pseudoaneurysms) are rare entities. Fifty‐eight per cent of extracranial dissections are carotid in origin and 88% present with infarct.1,2 Other presentations include cervical pain and/or headache, and incomplete Horner's syndrome.1 Rarely, dissection can cause severe dysphagia, neck swelling, dysphonia, and extremely rarely, rapidly life‐threatening airway obstruction.3,4 This is due to the symptomatic mass effect from retropharyngeal haematoma. Causes include penetrating or blunt carotid trauma, head and neck malignancy/irradiation, tonsillectomy or peritonsillar abscess, or cervical spine injury/manipulation, the others being attributed to spontaneous dissection.
Spontaneous dissections of the extracranial carotid artery occur most frequently in the internal carotid artery,1 and can present as respiratory distress due to great vessel compromise and upper airway obstruction. Several authors have described cases of presumed spontaneous carotid artery dissection; however, all of these eventually identified causative factors including aspirin ingestion, schistosomiasis, blood dyscrasias and trivial trauma. Only one case describes spontaneous cervical haematoma after straining, with parapharyngeal and retropharyngeal involvement, which caused near‐complete obstruction in an otherwise healthy young man.4
Diagnostic imaging can be used to confirm carotid artery dissection in the subacute patient. This can include the use of CT scan or MRI angiography (which has progressively replaced conventional angiography), MRI of the neck, digital subtraction angiography and serial Doppler ultrasonography. Doppler ultrasound remains the mainstay of imaging; however, one of every eight patients with proven carotid artery dissection will have negative initial ultrasound findings,2 necessitating serial ultrasound and further imaging, especially MRI.
Endovascular approaches for the repair of carotid artery pseudoaneurysms and dissections (including endoluminal stents and coil embolisation) are useful alternatives to standard surgical repair, and are rapidly gaining popularity. However, in the emergency setting, with a haemodynamically compromised patient, primary resuscitation and stabilisation is paramount. Local mass effect with or without massive haemorrhage precludes easy endotracheal intubation, with disastrous consequences for the patient by way of impending airway obstruction. Airway alternatives include fibreoptic nasotracheal intubation4 or immediate surgical airway pending definitive airway.
The present case illustrates that emergency care providers need to maintain a high index of suspicion for cervical vascular injury in cases of neck injury (even trivial), known head and neck malignancy/irradiation or coagulopathy. Importantly, the diagnosis must also be considered in patients who present with unilateral neck swelling and symptoms related to mass effect. In those patients, difficult intubation should be anticipated, and greater consideration given to its method and timing.
Competing interests: None.