Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Oct 26, 2020; 8(20): 4858-4865
Published online Oct 26, 2020. doi: 10.12998/wjcc.v8.i20.4858
Rupture of carotid artery pseudoaneurysm in the modern era of definitive chemoradiation for head and neck cancer: Two case reports
Myungsoo Kim, Ji Hyung Hong, Sang Kyu Park, Sook Jung Kim, Jung Hwi Lee, JH Byun, Yoon Ho Ko
Myungsoo Kim, Department of Radiation Oncology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon 403720, South Korea
Ji Hyung Hong, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon 21431, South Korea
Sang Kyu Park, Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
Sook Jung Kim, JH Byun, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
Jung Hwi Lee, Department of Radiology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
Yoon Ho Ko, Department of Internal Medicine, Eun-pyeoung St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, South Korea
Author contributions: Hong JH and Kim SJ who were the patients’ medical doctors, reviewed the literature and contributed to manuscript drafting; Kim M reviewed the literature and contributed to manuscript drafting; Park SK was the patient’s neurosurgeon and contributed to manuscript drafting for important intellectual content; Lee JH performed interpretation of data and contributed to manuscript drafting for important intellectual content; Ko YH and Byun JH were responsible for the conceptualization of this study; all authors issued final approval of the version to be submitted.
Informed consent statement: This case report was approved by the institutional review boards of The Catholic University of Korea, Incheon St. Mary's Hospital (No. PC19ZESE0074). Due to the nature of this study, the need for informed consent from the patients was waived.
Conflict-of-interest statement: The authors disclose no potential conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ji Hyung Hong, MD, PhD, Associate Professor, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 56, Dongsu-Ro, Bupyeong-Gu, Incheon 21431, South Korea. jh_hong@catholic.ac.kr
Received: August 25, 2020
Peer-review started: August 25, 2020
First decision: September 12, 2020
Revised: September 18, 2020
Accepted: September 28, 2020
Article in press: September 28, 2020
Published online: October 26, 2020
Processing time: 62 Days and 4.8 Hours
Abstract
BACKGROUND

Carotid blowout syndrome (CBS) is a rupture of the carotid artery and is mainly caused by radiation and resection of head and neck cancers or direct tumor invasion of the carotid artery wall. It is a life-threatening clinical situation. There is no established and effective mode of management of CBS. Furthermore, there is no established preceding sign or symptom; therefore, preventive efforts are not clinically meaningful.

CASE SUMMARY

We described two cases of CBS that occurred in patients with head and neck cancer after definitive chemoradiotherapy (CRT) using three-dimensional conformal intensity-modulated radiation therapy. Two men aged 61 and 56 years with locally advanced head and neck cancer were treated with definitive CRT. After completing CRT, both of them achieved complete remission. Subsequently, they had persistent severe pain in the oropharyngeal mucosal region and the irradiated neck despite the use of opioid analgesics and rehabilitation for relief of contracted skin. However, continuous follow-up imaging studies showed no evidence of cancer recurrence. Eleven to twelve months after completing CRT, the patients visited the emergency room complaining about massive oronasal bleeding. Angiograms showed rupture of carotid artery pseudoaneurysms on the irradiated side. Despite attempting to secure hemostasis with carotid arterial stent insertion and coil embolization, both patients died because of repeated bleeding from the pseudoaneurysms.

CONCLUSION

In patients with persistent pain in irradiated sites, clinicians should be suspicious of progressing or impending CBS, even in the three-dimensional conformal intensity-modulated radiation therapy era.

Keywords: Carotid blow-out syndrome; Carotid pseudoaneurysm; Head and neck neoplasms; Radiation injuries; Severe pain; Case report

Core Tip: Even though recent endovascular interventions show a moderately successful hemostasis rate, carotid blowout syndrome (CBS) is still a life-threatening complication of radiotherapy of head and neck cancer. Here, we described CBS in two patients who achieved complete remission after definitive chemoradiotherapy but later developed persistent severe pain in the irradiated region. Clinicians should be suspicious that pain can be a sign of progressing or impending CBS, and in such cases, they should consider the rapid adoption of angiographic endovascular intervention to prevent patients from developing devastating hypovolemic shock.