0:00

This was an individual who had had surgery on the

0:04

neck as well as radiation on the neck

0:07

for a cancer of the oropharynx.

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The patient presented with neurologic deficits

0:14

on the left side of the body,

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and they were concerned about the right internal

0:17

carotid artery in the operated and radiated field.

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So let's follow up the CTA here.

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How do we know this is CTA? We're seeing the artery,

0:27

but not the vein.

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So this has been timed to show the carotid artery

0:31

and the vertebral artery. As we proceed upward,

0:35

we see the changes that are manifest

0:37

from radiation treatment,

0:40

and that is diffuse edema of the subcutaneous fat,

0:43

diffuse edema of the platysma muscle.

0:45

The supraglottic larynx, as you can see,

0:47

is swollen with mucosal thickening.

0:51

The whole neck just kind of looks a little

0:53

bit dirty fat. As we continue superiorly,

0:57

we come to the carotid bifurcation.

0:58

We're not looking too bad.

1:00

You can see that the common carotid artery has soft

1:05

tissue around it and loss of the fat planes

1:08

compared to the left side. It doesn't look too bad.

1:12

Here's the...

1:12

if we follow this right internal carotid artery,

1:14

we see the left on the contralateral side,

1:17

and we see there is a change in

1:18

the lumen between the two.

1:20

But as we follow this internal carotid artery

1:24

superiorly, we see that we lose it.

1:27

It just kind of, the lumen narrows dramatically,

1:31

and we have all of this soft tissue thickening. Here's

1:35

the normal left internal carotid artery and the

1:39

normal parapharyngeal space. Here's the styloid process.

1:42

Here we have loss of the internal carotid artery

1:46

and this soft tissue here. At arteriography,

1:50

this was what we would call a carotid blowout.

1:52

You can actually see some of the luminary irregularity

1:57

and some contrast leaking out of the

2:00

internal carotid artery. So how does this happen?

2:02

Well, the carotid artery typically can tolerate

2:06

radiation therapy, obviously,

2:08

because we do a lot of radiation therapy to the neck.

2:10

In this setting where you had both surgery

2:13

as well as radiation therapy,

2:15

the wall of the carotid artery was injured and this

2:18

patient's carotid artery kind of exploded into this

2:22

parapharyngeal space and you had

2:24

what is called carotid blowout.

2:26

So any radiated operated right internal carotid

2:31

artery where the lumen has been violated and this

2:37

whole process here was clotted up blood

2:41

in the parapharyngeal space,

2:43

carotid blowout on the right side.