Aneurysm of the Extracranial Carotid Artery with Spontaneous Echo Contrast Revealed by Duplex Sonography

Abstract

A 56-year old male patient without cerebrovascular disease or risk factors presented with a painless, pulsatile right-sided cervical swelling. Ultrasonography showed a large aneurysm of the right common and internal carotid artery with homogeneous thickening of the vessel wall as well as a parietal thrombus and a dilation of the left common and internal carotid artery with markedly reduced blood flow velocities. In the enlarged lumen of the right internal carotid artery spontaneous echo contrast was apparent with slow, ineffective but orthograde blood flow motions. Ensuing diagnostic procedures revealed multiple aneurysms involving the aorta and its branches. Despite surgical removal of the aneurysm and glucocorticoid therapy, the patient died from a ruptured aneurysm of a coronary artery a few weeks later. Post-mortem examination showed panarteritis consistent with Takayasu's disease. Spontaneous echo contrast is a frequent echocardiographic finding in patients with atrial fibrillation and mitral stenosis, indicating decreased blood flow. This is associated with an increased risk of embolism. In our patient, spontaneous echo contrast indicated severely disturbed haemodynamics due to a large aneurysm of the carotid artery. In the rare case of multiple aneurysms, differential diagnosis should include dissections, infections, and connective tissue diseases. Takayasu's arteritis, however, should also be considered, which usually presents with stenoses, but may be associated with multiple aneurysms of the aorta or its branches. If the diagnostic criteria are present, immunosuppressive treatment should be initiated.

Multiple aneurysms with different kinds of external carotid artery associated with multiple aneurysms of internal carotid artery

“…However, multiple ECA aneurysms of different kinds, in the absence of these factors, are rather rare. [1,2] To the best of our knowledge, this type of case, simultaneous occurrence of multilple ICA aneurysms, [3,4] has not previously been reported. …”

Nicht arteriosklerotische Erkrankungen der Halsarterien

“…Im Very proximal vasoconstriction at the point where the branches leave the aorta cannot be directly visualized with cervical artery sonography, however, severe stenosis can be detected using hemodynamic stenosis criteria. TA can also result in aneurysm formation [24]. When located very proximally near the vascular origins of the aortic arch these aneurysms can be missed by sonography.…”

“…Sehr weit proximal, unmittelbar an den Abgängen aus der Aorta lokalisierte Gefäßstenosen sind mit der Technik der Halsarteriensonografie nicht direkt darstellbar, bei hohem Stenosegrad aber mit hämodynamischen Stenosekriterien erkennbar. Die TA kann auch zur Ausbildung von Aneurysmen führen [24]. Diese können dem sonografischen Nachweis entgehen, wenn sie weit proximal, nahe den Gefäßabgängen aus dem Aortenbogen lokalisiert sind.…”

Extracranial Carotid Aneurysms

“…True aneurysms may coexist with congenital abnormalities and occur in Marfan's syndrome, cystic necrosis of intima media, fibromuscular dysplasia, nodular arteritis, granuloma or giant cell arteritis, neurofibromatosis, Pseudoaxanthoma elasticum, Behçet's and Takayasu's syndromes, and after neck irradiation (14,15,16).…”