0:00

So we've completed our sixth scenario of the head and neck and spine

0:06

portion of the emergency radiology evaluation of neuroradiological abnormalities.

0:13

I just wanna finish with a few final comments. There are some head

0:18

and neck emergencies that do require imaging evaluation. And although they're

0:24

very uncommon, they are life threatening. And the things that I wanna mention

0:28

are these entities: Carotid blowout after treatment, invasive fungal sinusitis.

0:35

I mentioned previously necrotizing fasciitis, let's look at one more case

0:39

of that. And then epidural abscesses, either from sinusitis or Otomastoiditis.

0:45

These are life threatening emergencies, but you probably will only see one

0:49

or two of them each year. So let's start with carotid blowout, what

0:53

do we mean by that? This is where the carotid wall is

0:57

damaged, either due to the primary tumor of a head and neck malignancy

1:03

encasing the carotid artery or due to surgery or radiation therapy that's

1:09

been performed in order to peel tumor off of the carotid artery or

1:13

cure tumor from the carotid artery with radiation therapy.

1:18

You may also see this in some cases after trauma where the patient

1:22

has a pseudoaneurysm and suddenly the patient bleeds into the neck.

1:27

So let's start with that and then we'll continue on with invasive fungal

1:32

sinusitis. Here's a patient who, as you can see, has a head and neck

1:39

cancer with nasopharyngeal carcinoma. On the right side,

1:44

we see an irregular appearance to the internal carotid artery in its cervical

1:50

portion compared to the normal left side with a nice smooth rounded margin.

1:57

As we go further in superiorly, you see that the carotid artery actually

2:02

is quite narrow and it seems to be encased with tumor.

2:06

Now this patient has encasement of the carotid artery with tumor,

2:10

but has superimposed radiation treatment on that leading to a vasculopathy.

2:17

If you look at the patient's angiogram, you're just sort of horrified at

2:22

the appearance of the internal carotid artery. Here's the internal carotid

2:26

artery. Here is the external carotid artery and we see coming superiorly

2:31

that the carotid artery markedly narrows and it looks quite irregular. And

2:36

then you have the pseudoaneurysm of the vessel wall, which is corresponding

2:42

to this lower signal intensity area adjacent to the contrast on the CT

2:48

scan. This carotid artery is in very bad shape and more likely than

2:53

not, the clinicians will decide to do a temporary balloon occlusion

2:59

followed by a permanent balloon occlusion if the patient does not develop

3:02

neurologic symptoms. Fortunately, I guess because this is likely to have

3:08

such little and poor flow through it, the likelihood that the patient's

3:12

going to have symptoms with a temporary balloon occlusion test is actually

3:16

quite small. So this is one of the emergencies because two things can

3:22

happen, the vessel can occlude completely, or the pseudoaneurysm can start

3:27

bleeding into the neck, and next thing you'll see is extravasation of contrast

3:32

into this parapharyngeal soft tissue. Here for example is an example of

3:37

just that. Here is a patient who had head and neck cancer,

3:41

developed a pseudoaneurysm and started to have bleeding into the floor of

3:46

the mouth and oropharyngeal tissues. You notice here that there is hemorrhage

3:52

and blood products that are seen accumulating in the floor of the mouth.

3:56

This is not contrast in a normal blood vessel, but leakage into a

4:01

necrotic area at the tonsil tongue base junction, so the glossotonsillar

4:08

sulcus. And we have this leakage of contrast, which is seen here from

4:13

the hemorrhage that's occurring from a pseudoaneurysm that developed after

4:19

treatment for head and neck cancer. On the sagittal reconstruction, you

4:23

can see the irregularity of the blood vessel that was leading to the

4:27

hemorrhage. Notice that the patient has necrosis in the adjacent soft tissue,

4:32

this is air in the adjacent soft tissue of the tonsil secondary to

4:37

the radiation necrosis. So very poor prognosis, not much to do here.

4:43

Fortunately, this is not the internal carotid artery, this is the external

4:47

carotid artery and that can be sacrificed quite readily.

4:51

The other scenario where you have bleeding out from carotid injury may be

4:57

from a penetrating wound. Here we have a patient who... Actually,

5:02

this is a pen that was jabbed into the individual during an altercation,

5:08

and you see that it's going across the soft tissues of the neck

5:11

and actually is embedded in one of the thoracic vertebrae. Unfortunately,

5:17

either from something like a pen or from bullet fragments,

5:22

you may completely injure your carotid artery, be it the external or the

5:27

internal carotid artery, which can lead to extravasation into the neck,

5:32

another emergency that has to be dealt with as part of your head

5:36

and neck neuroradiology experience. Here, for example, is the CTA. We have

5:43

a carotid artery here. We actually don't see the carotid artery here.

5:47

We don't see the carotid artery in the petrous internal carotid artery.

5:51

That's because this has just been blown apart and some of this is

5:55

bone fragment, some of this is metal fragment, but some of this is

5:59

extravasation of contrast from the perforated, left internal carotid artery.

6:06

Because this patient was having neck pain and a drop in the hematocrit,

6:12

the patient was taken to evaluation with conventional arteriography. Here

6:18

you can see the CTA reconstruction of the patient showing the carotid artery,

6:25

the common carotid artery here, and then the stump of an internal carotid

6:31

artery and then the irregularity of the external carotid artery branches.

6:37

The patient went to conventional arteriography and because there was leakage

6:42

of the external and internal carotid arteries, you see that they used extensive

6:48

coiling. This is the metal from the bullet wounds

6:52

and they occluded the internal carotid artery so that way it would not

6:57

continue to bleed out. So this patient had both external as well as

7:02

internal carotid artery source of the hemorrhage in the left side of the

7:06

neck.