Discussion and Conclusions
Carotid artery injury is known as carotid blowout syndrome (CBS); to
date, no case of idiopathic CBS has been reported. Moreover, CBS results
from blood vessel wall necrosis due to surgical resection or radiation
therapy for head and neck cancer. Other causes include blunt trauma or
medically-induced injury during surgery. Hence, some types of trauma
trigger CBS.
CBS is an infrequent, but rapidly fatal condition if diagnosed late. The
present case does not fit the abovementioned causes because the patient
only had a history of hypertension and smoking.
The preliminary CT scan did not clearly show extravasation, probably
because the wound was compressed by the large hematoma. We considered
angiography, including a Matas test [8, 9]; nevertheless, because
our facility was a general city hospital, it was difficult to perform an
endovascular treatment in the head and neck region [10]. In
addition, the airway emergency made it difficult to transfer the patient
to a facility where the procedure could be performed; therefore, we
prioritized swelling exploration through an external incision.
After a retrospective review of the contrast-enhanced CT images, a small
extravasation that appeared to be a hemorrhage point was observed in one
CT image slice, although it was not initially highlighted. Postoperative
three-dimensional images also revealed that the same site was the source
of the idiopathic hemorrhage (Figure 4A, B).
A careful analysis of the CT images could have led to a preoperative
detection of extravasation. Nonetheless, we did not consider the
diagnosis of common carotid artery disruption; hence, we did not make a
good judgment.
Small lacerations can be sutured intraoperatively, whereas large
lacerations require reconstruction by grafting the external jugular vein
patch or its vein wall [11], which necessitates prior imaging
information.
In conclusion, this case demonstrates that if a neck hematoma is
suspected on imaging in a young patient with no history of head and neck
cancer surgery, radiotherapy, or trauma, it is necessary to consider
bleeding from the main trunk of the carotid artery and establish an
effective system for surgery.