Carotid rupture

This operation was performed for late carotid rupture following neck trauma in an attempted suicide. The first successful ligation for carotid aneurysm was performed five years later in London by Astley Cooper (Cooper 1836). By 1868, Pilz was able to collect 600 recorded cases of carotid ligation for cervical aneurysm or hemorrhage, with an overall mortality of 43% (Hamby 1952). In 1878, an American surgeon named John Wyeth reported a 41% mortality in a collected study of 898 common carotid ligations, and contrasted this with a 4.5% mortality for ligation of the external carotid artery. 

The apoplectic consequences of a ruptured carotid artery have been well recognized for centuries, dating back to antiquity. In both the distant and near past, this catastrophe was exclusively the result of a penetrating injury derived from an act of warfare or accident. Surgical intervention for treatment of carotid rupture is also historically relatively old, predating modern neurosurgical practice for more than 100 years [1]. John Abernathy, a former pupil... 

Despite anecdotal reports of technical and clinical success of simple operative ligation for the treatment of carotid rupture, most open surgical series reported over the last few decades have shown exceedingly high rates of mortality and morbidity associated with this complication. Emergent opera-... 

Sanders EM, Davis KR, Whelan CS, Deckers KR (1986) Threatened carotid rupture a complication of radical neck surgery. J Surg One 33 190-193... 

Zimmerman MC, Mickel RA, Kessler DJ, et al. (1987) Treatment of impending carotid rupture with detachable balloon embolization. Arch Otolaryngol Head Neck Surg 113 1169-1175... 

Dissection of the internal carotid and vertebral arteries is a common cause of stroke, particularly in young patients. Although many occur due to trauma, it is estimated that over half occur spontaneously. The mechanism of stroke following arterial dissection is either by artery-to-artery embolism, by thrombosis in situ, or by dissection-induced lumenal stenosis with secondary cerebral hypoperfusion and low-flow watershed infarction. Occasionally, dissection may lead to the formation of a pseudoaneurysm as a source of thrombus formation. Vertebrobasilar dissections that extend intracranially have a higher risk of rupture leading to subarachnoid hemorrhage (SAH). ° ... 

In carotid atherosclerosis, plaques may rupture, resulting in collagen exposure, platelet aggregation, and thrombus formation. The clot may cause local occlusion or may dislodge and travel distally, eventually occluding a cerebral vessel. 

Embolism from thrombus within the cavity of an aneurysm is rare and is difficult to prove in cases where there maybe other potential sources of embolization. Intracranial aneurysms more commonly present with rupture and subarachnoid hemorrhage, whereas internal carotid artery aneurysms tend to cause pressure symptoms including a pulsatile and sometimes painful mass in the neck or pharynx, ipsilateral Horner s syndrome or compression of the lower cranial nerves. Extracranial vertebral artery aneurysms may cause pain in the neck and arm, a mass, spinal cord compression and upper limb ischemia (Catala et al. 1993). 

Sometimes arterial occlusion is demonstrated by angiography in migrainous stroke and the cause is hypothesized to be in-situ thrombosis complicating vasospasm. No provoking factors are known. Other possible causes of stroke in the context of headache must be considered carotid dissection, mitochondrial cytopathy, ruptured vascular malformation, antiphospholipid antibody syndrome and CADASIL (cerebral autosomal dominant arterio-pathy with subcortical infarcts and leukoencephalopathy). Migraine auras without headache may be confused with TIA (Ch. 8). 

Gronholdt MLM (1999). Ultrasound and lipoproteins as predictors of lipid-rich rupture-prone plaques in the carotid artery. Arteriosclerosis Thrombosis and Vascular Biology 19 2-13... 

Moyamoya syndrome (Ch. 6) causes gradual stenosis or occlusion of the terminal portions of the internal carotid arteries or middle cerebral arteries. This leads to formation of an abnormal collateral network of fragile vessels, which occasionally rupture. It has been proposed that constructing a bypass to relieve the pressure on the collaterals would be beneficial, for example between the superficial temporal artery and the middle cerebral... 

Approximately 85% of spontaneous SAHs are caused by ruptured aneurysm 10% are perimesencephalic and the remainder are caused by rare disorders (van Gijn and Rinkel 2001). The pattern of bleeding on CT is a clue to the underlying cause. Blood in the interhemispheric fissure suggests an anterior communicating artery aneurysm and in the sylvian fissure suggests internal carotid artery or middle cerebral artery aneurysm (Fig. 30.1). 

The crosslinking reagent is important in the case of bovine carotid heterografts. Chrome-tanned grafts had a high incidence of thrombosis whereas aldehyde-treated ones functioned well. Formalin-treated grafts tended to be weak, but glutaraldehyde-treated ones did not rupture (21). 

Cerebrovascular disease is a consequence of hypertension. A neurologic assessment can detect either gross neurologic deficits or a slight hemiparesis with some incoordination and hyperreflexia that are indicative of cerebrovascular disease. Stroke can result from lacunar infarcts caused by thrombotic occlusion of small vessels or intracerebral hemorrhage resulting from ruptured microaneurysms. Transient ischemic attacks secondary to atherosclerotic disease in the carotid arteries are common in hypertensive individuals. 

Type 1 aortic dissection is one of the most difficult vascular lesions to manage in the presence of major stroke. The patient may present with chest pain and asymmetric pulses. Stroke may occur in the distribution of any major cerebral arteries because the dissection can involve both carotid and vertebral origins [28], Since rupture into the chest or extension of dissection into the pericardium or coronary origins is fatal, thrombolysis or anticoagulation cannot be used. 

Infrequently, cervical artery dissection can lead to subarachnoid hemorrhage, usually when the dissection extends to the intracranial part of the vessel, with pseudoaneurysm formation and rupture (1% of cervical artery dissection cases in the large hospital-based series) [36, 37], Rupture of dissected vertebral arteries into the subarachnoid space is more common in children. Rupture of dissected carotid artery pseudoaneurysms into the neck or nasal sinuses is generally rare. Dissection can occur intracraiually and, on rare occasions, can spread intracraniaUy from a primary extracranial origin. 

Nose Blood Chronic ulceration Potential site of bleeding after thrombolysis. Osier Weber Rendu syndrome Occasionally secondary to dissecting carotid artery rupture Nasopharyngeal carcinoma, Wegener s, with cranial nerve involvement... 

John TG, Bradbury AW, Ruckley CV. Vein-patch rupture after carotid endarterectomy an avoidable catastrophe. BrJ Surg 1993 80 852-3. 

Riles TS, Lamparello PJ, Giangola G, Imparato AM. Rupture of the vein patch a rare complication of carotid endarterectomy. Surgery 1990 107 10-2. 

Scott EW, Dolson L, Day AL, Seeger JM. Carotid endarterectomy complicated by vein patch rupture. Neurosurgery 1992 31 373-6. 

Archie JP. Carotid endarterectomy saphenous vein patch rupture revisited selective use on the basis of vein diameter. J Vase Surg 1996 24 346-52. 

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