Case presentation
A 52-year-old man with a history of hypertension and smoking (32
pack-years) presented to our emergency department with a complaint of
sudden neck pain and swelling that had been evolving for approximately 3
h before consultation, without any apparent trigger. He had no history
of neck surgery, puncture, trauma, or irradiation.
His body temperature, blood pressure, heart rate, and
SpO2 were 36.2°C, 177/111 mmHg, 75 beats/min, and 99%,
respectively. Physical examination revealed a swelling on the left side
of the neck with no warmth or trauma scars. Palpation revealed a
gradually widening left cervical tightness.
Laryngoscopy revealed a slowly progressive laryngeal edema with no
obvious mass or bleeding. Contrast-enhanced computed tomography (CT)
showed a widespread low-absorption area without contrast effect or ring
enhancement in the left cervical region; no abscess or active bleed was
observed.
Neck ultrasonography showed uniform hypoechoic areas with absence of
blood flow around the cervical vessels and thyroid gland; moreover,
there were no findings suggesting bleeding from the main cervical
artery.
Magnetic resonance imaging was not performed due to the emergency.
Although the various examinations did not establish the source of
bleeding, we considered that the swelling was a cervical hematoma
inducing gradual supraglottic stenosis. However, no extravasation was
observed in both arterial and venous phases during contrast-enhanced CT
[1].
Tumor was also considered as a differential diagnosis, although it was
unlikely because of the rapid progression of symptoms over a few hours.
In addition, the patient had no history of trauma or irradiation; thus,
we suspected a disruption of a peripheral branch of the cervical artery
or bleeding from the parathyroid gland, which has been reported in
numerous cases [2-4].
Therefore, we performed a trial cervical opening and tracheotomy under
general anesthesia to identify the bleeding source on the left side of
the neck and secure the airway. A skin incision was made over the
sternocleidomastoid muscle to easily reach the hematoma cavity (Figure
1).
The hematoma was removed while checking the main arteriovenous system to
avoid intraoperative damage to the system. When most of the hematoma was
removed, a large amount of blood suddenly gushed out from an
unidentified source; the blood even reached the surgeon’s face, who was
in an upright standing position. We did not suspect a bleeding source
other than the common carotid artery. The left common carotid artery was
examined, and a blunt laceration of approximately 3 mm length was found
on the medial side of the main trunk, leading to the diagnosis of
idiopathic common carotid artery laceration. There was no damage to the
outer wall of the common carotid artery or any other structure around
the sternocleidomastoid muscle; hence, we maintained the diagnosis of
idiopathic carotid artery laceration.
A vascular tape [5] was used to apply cephalic and caudalic manual
compression to the common carotid arteries to temporarily block blood
flow; after blood flow interruption, a blunt injury of approximately 3
mm was observed on the medial side of the carotid artery (Figure 2).
A long interruption time of blood flow poses a risk of cerebral
infarction and hypoxic encephalopathy [6, 7]; hence, we initiated
immediate common carotid artery reconstruction in the short-axis
direction (using 8-0 absorbable suture) under microscopic guidance,
while adequately monitoring oxygen saturation and blood flow
interruption time. The area surrounding the laceration was covered with
Surgicel cotton (Figure 3A, B). The total blood flow interruption time
was 31 min. Finally, tracheotomy was performed to complete the surgery.
The total blood loss was 537 mL, and postoperative hemoglobin levels
remained stable; therefore, blood transfusion was not performed. The
postoperative course was favorable, and the patient was weaned off the
ventilator on postoperative day (POD) 1. There were no cerebral or
neurological complications, and the rehabilitation course was favorable.
The tracheal foramen was closed on POD 15, and the patient was
discharged on POD 18. The patient provided informed consent, and the
study design was approved by the appropriate ethics review board.