Carotid blowout syndrome (CBS) is a rare potentially life-threatening oncological emergency that occurs in patients treated for head and neck malignancy due to rupture of the extracranial carotid artery or one of its major branches. CBS is categorized into three major types [1]. Threatened (type I) CBS is characterized by carotid artery exposure on physical examination. On vascular imaging, it can be seen as air surrounding the artery with or without abscess, tumor-related fistula or areas of focal arterial wall disruption; however, none of these are characteristic imaging features. Impending blowouts (type II) are sentinel bleeding episodes that can cease temporarily with pressure. On cross-sectional imaging, it is characterized by the presence of a pseudoaneurysm without contrast extravasation. Acute CBS hemorrhage (type III) is life threating, and contrast extravasation is imaging indicator of bleeding point [2].CBS is the result of arterial adventitia ischemia, which can occur following neck dissection with stripping of the carotid sheath, after irradiation for a tumor, by direct tumor invasion of the carotid artery wall, infection and effect of salivary enzymes or multifactorial conditions. The incidence of CBS in head and neck surgery is 3–4.5% [3]. Previous irradiation for head and neck tumors increases the risk of CBS by 7.6 times [4]. Empirical diagnostic CT angiography, catheter embolization and selection of optimal embolic agents can result in optimum life-saving hemostasis.
Case presentations-1
A 52-year-old man with history of smoking and moderate alcohol drinking (no other relevant medical history) was diagnosed with a right retromolar trigone region malignancy, staged as T3 N1Mx. He underwent chemoradiotherapy treatment (70 Gy of external radiotherapy plus cisplatin). After 6 months of follow-up without any warning signs or symptoms, the patient had an episode of sudden, massive oral hemorrhage at home, subsequently he was hospitalized. Fluid therapy and blood transfusion were given. He was planned for CT angiography as mouth opening was limited to direct endoscopy examination, which depicted large pseudoaneurysm from the right facial artery associated with multiple air foci adjacent to it (Fig. 1a–c). Patient was taken up for DSA coil embolization of facial artery using scaffolding technique (Figs. 1d–f, 2a–c). Results were satisfactory with no residual filling of the sac from contralateral side (Fig. 3a, b). Patient was discharged and is on follow-up in oncology department currently.
Case presentation-2
A 60-year-old male was presented with bleeding per oral in casualty. Examination showed multiple clots in the oral cavity. The patient was in shock. Hemogram revealed hemoglobin of 7 g/dl. Fluid replacement and blood transfusion were given to stabilize the patient. Coagulation parameters were in normal limit. Patient was a diagnosed case of T3N2 laryngeal cancer for which concurrent chemoradiation (70 Gy of external radiotherapy and cisplatin) was started a year back which the patient could not follow up. As there was limited mouth opening and patient had severe nausea, nasal intubation was done. After the patient was hemodynamically stabilized, CT angiography was carried out which showed extravasation of contrast adjacent to the right ECA (Fig. 4a–c). The patient was then taken up for transfemoral digital subtraction angiogram (DSA) of neck vessels which showed irregularity of the right ECA wall medially, correlating with site of extravasation on CT angiography (Fig. 4d–f). Following this, the coil embolization with anchoring technique (Fig. 5a–c) was done for which the results were satisfactory (Fig. 6a–c). He was given proper fluid support intravenously and was monitored closely. Patient was extubated and subsequently discharged. Currently, he is on follow-up in the oncology department.