Pseudoaneurysm of internal carotid artery after carotid body tumor excision
A 35-year-old male patient presented with swelling in the left side of the neck. USG and magnetic resonance imaging (MRI) revealed a well-marginated mass lesion measuring 3.8 cm × 2.8 cm at the left carotid bifurcation [] splaying the proximal internal and external carotid arteries, with circumferential area of contact with ICA of 180°-270°, consistent with the imaging diagnosis of Shamblin stage 2 CBT. Subadventitial excision of CBT was done after retraction of the carotids. No special technique was used to visualize the tumor and the excision was simple. Proximal and distal control of the internal, external, and common carotid arteries was done over vascular loops and the vessel loops were used to retract the external and internal carotid artery bifurcation. There were no arterial or nerve injuries. No preoperative embolization was planned. The postoperative course was uneventful and the patient was given intraoperative heparin based on body weight. No neurological deficits were observed at recovery or in the immediate postoperative period. The patient developed right-sided dense hemiplegia on the morning of the first postoperative day, with a score of 29/48 according to the Scandinavian Stroke scale.[] Plain computed tomography (CT) of the brain [] revealed a recent infarct involving the left capsuloganglionic region and corona radiata (middle cerebral artery territory). Color Doppler of the carotid arteries [] revealed partial thrombosis of the left ICA with approximately 50% reduction in vessel lumen and hypoechoic hematoma around the proximal ICA, consistent with a diagnosis of postoperative dissection. Patient was managed conservatively with low molecular weight (LMW) heparin. In view of ICA thrombus, oral warfarin was started and LMW heparin was stopped after 5 days. Two weeks later, a follow-up carotid Doppler study [] showed a pseudoaneurysm measuring 2.3 cm × 1.5 cm in the medial aspect of proximal left ICA with a central patent lumen of size 10 mm × 8 mm and a mural thrombus around it. Neck of the pseudoaneurysm measured 2 mm. ICA thrombus had significantly resolved with good distal flow. Carotid angiography done on the 17th postoperative day [] showed a pseudoaneurysm measuring 2.3 cm × 1.8 cm, medial to the proximal left ICA filling through a small neck of 2 mm []. Intimal irregularity was noted in the lateral wall of the left ICA, suggesting arterial injury/dissection. The neck of the pseudoaneurysm was very narrow, so a 0.018-inch guide wire could not be negotiated and attempts to close the pseudoaneurysm were not successful. Microcatheters and stent grafts were not available in our hospital, as it was a primitive hospital set-up. Non-invasive methods were avoided in this patient because he developed stroke on the first postoperative day, mandating anticoagulation. In view of the ICA pseudoaneurysm and no significant intraluminal thrombus in ICA on angiogram, he was started on oral antiplatelets (aspirin) on the 18th postoperative day and oral anticoagulant was stopped after 2 days. But the pseudoaneurysm had spontaneously thrombosed with no demonstrable flow into the aneurysm in follow-up Doppler done after a week of stopping anticoagulants. There was minimal hypoechoic intimal thickening and irregularity of the proximal ICA with no significant lumen narrowing, thrombus, or false lumen. The patient was continued on oral antiplatelets for 6 months, and is on regular follow-up for 5 years. His neurological weakness has improved significantly with regular physiotherapy.