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.