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Case 412

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Female, 58 years old, has abrupt paresthesia in the left upper limb, associated with ipsilateral cervical bulging with progressive growth for 2 years. Former smoker, abstained for 3 years, with no history of cervical trauma — perforating or blunt — or catheter puncture. Upon examination, an extensive cervical mass is detected on the left, pulsatile and painless on palpation.

From the clinical and radiological data presented, it is concluded that the patient has:

a) Carotid body tumor (paraganglioma)

25%

b) Sacular aneurysm of the internal carotid artery

25%

c) Dolicoarteriopathy of the internal carotid artery

25%

d) Cystic Hygroma

25%
   

Image Analyses

Image 1: CT angiography of the cervical vessels, coronal reconstruction in Maximum Intensity Projection (MIP), arteriovenous phase. In this image, we can distinguish the internal carotid arteries (in red) and the external ones (in blue, emerging laterally). In addition, an extensive saculiform dilatation is noted right after the left common carotid artery bifurcation (yellow arrows) at the level of C2 and C3.

 

Image 2: Computed angiotomography of the cervical vessels, axial reconstruction in MIP at the C3 level, arteriovenous phase. A saculiform dilation is evident from the left internal carotid artery (yellow arrows).

 

Image 3: Three-dimensional reconstruction of computed angiotomography of cervical vessels. Formation of saculiform structure from the left internal carotid artery (yellow arrows).

Highlights:

- Aneurysm of the internal carotid artery (AIC) is a rare condition that should be considered in patients with pulsatile cervical masses;

  • - It seems to be related to atherosclerosis, infectious, inflammatory and collagen diseases;

  • - Vascular ultrasound is used at the initial evaluation of patients with pulsatile cervical mass;

  • - Contrasted CT and magnetic resonance imaging are tests of excellent accuracy in the evaluation of patients with cervical disorders of vascular origin;

  • - The (AIC) has high mortality linked to its natural course, mainly due to the involvement of the central nervous system;

  • Surgical and antithrombotic treatment of extracranial ACI should be performed in all patients despite the absence of symptoms.

References

1. Longo G, Kibbe M. Aneurysms of the Carotid Artery. Seminars in Vascular Surgery. 2005;18(4):178-183;

2. Welleweerd J, den Ruijter H, Nelissen B, Bots M, Kappelle L, Rinkel G et al. Management of Extracranial Carotid Artery Aneurysm. European Journal of Vascular and Endovascular Surgery. 2015;50(2):141-147;

3. Eckstein H. European Society for Vascular Surgery Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. European Journal of Vascular and Endovascular Surgery. 2018;55(1):1-2;

4. Fankhauser G, Stone W, Fowl R, O'Donnell M, Bower T, Meyer F et al. Surgical and Medical Management of Extracranial Carotid Artery Aneurysms. Journal of Vascular Surgery. 2013;57(1):291;

5. Silvestri V, Borrazzo C, Mele R, d'Ettorre G. Carotid Artery Aneurysm in HIV: A Review of Case Reports in Literature. Annals of Vascular Surgery. 2020;63:409-426.

Author

Mariana Alcântara Nascimento, 6th year medical student at UFMG.

Mail: mari.alcantara.nascimento[at]gmail.com

Supervisors

Alberto Okuhara, vascular surgeon and professor at the Department of Surgery, Faculty of Medicine, UFMG

Mail: alberto.hara[at]yahoo.com.br

 

Pedro Augusto Lopes Tito, radiologist, professor at the Department of Anatomy and Image at UFMG.

Mail: ipedrotito[at]gmail.com

Reviewers:

Leandra Diniz, Almir Marquiore Júnior, Marco Fontana, Professor Júlio Guerra Domingues.

 

Test question

a)

25%

b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

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