Interactive Transcript
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So we've completed our sixth scenario of the head and neck and spine
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portion of the emergency radiology evaluation of neuroradiological abnormalities.
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I just wanna finish with a few final comments. There are some head
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and neck emergencies that do require imaging evaluation. And although they're
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very uncommon, they are life threatening. And the things that I wanna mention
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are these entities: Carotid blowout after treatment, invasive fungal sinusitis.
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I mentioned previously necrotizing fasciitis, let's look at one more case
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of that. And then epidural abscesses, either from sinusitis or Otomastoiditis.
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These are life threatening emergencies, but you probably will only see one
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or two of them each year. So let's start with carotid blowout, what
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do we mean by that? This is where the carotid wall is
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damaged, either due to the primary tumor of a head and neck malignancy
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encasing the carotid artery or due to surgery or radiation therapy that's
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been performed in order to peel tumor off of the carotid artery or
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cure tumor from the carotid artery with radiation therapy.
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You may also see this in some cases after trauma where the patient
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has a pseudoaneurysm and suddenly the patient bleeds into the neck.
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So let's start with that and then we'll continue on with invasive fungal
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sinusitis. Here's a patient who, as you can see, has a head and neck
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cancer with nasopharyngeal carcinoma. On the right side,
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we see an irregular appearance to the internal carotid artery in its cervical
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portion compared to the normal left side with a nice smooth rounded margin.
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As we go further in superiorly, you see that the carotid artery actually
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is quite narrow and it seems to be encased with tumor.
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Now this patient has encasement of the carotid artery with tumor,
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but has superimposed radiation treatment on that leading to a vasculopathy.
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If you look at the patient's angiogram, you're just sort of horrified at
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the appearance of the internal carotid artery. Here's the internal carotid
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artery. Here is the external carotid artery and we see coming superiorly
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that the carotid artery markedly narrows and it looks quite irregular. And
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then you have the pseudoaneurysm of the vessel wall, which is corresponding
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to this lower signal intensity area adjacent to the contrast on the CT
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scan. This carotid artery is in very bad shape and more likely than
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not, the clinicians will decide to do a temporary balloon occlusion
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followed by a permanent balloon occlusion if the patient does not develop
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neurologic symptoms. Fortunately, I guess because this is likely to have
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such little and poor flow through it, the likelihood that the patient's
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going to have symptoms with a temporary balloon occlusion test is actually
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quite small. So this is one of the emergencies because two things can
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happen, the vessel can occlude completely, or the pseudoaneurysm can start
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bleeding into the neck, and next thing you'll see is extravasation of contrast
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into this parapharyngeal soft tissue. Here for example is an example of
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just that. Here is a patient who had head and neck cancer,
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developed a pseudoaneurysm and started to have bleeding into the floor of
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the mouth and oropharyngeal tissues. You notice here that there is hemorrhage
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and blood products that are seen accumulating in the floor of the mouth.
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This is not contrast in a normal blood vessel, but leakage into a
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necrotic area at the tonsil tongue base junction, so the glossotonsillar
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sulcus. And we have this leakage of contrast, which is seen here from
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the hemorrhage that's occurring from a pseudoaneurysm that developed after
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treatment for head and neck cancer. On the sagittal reconstruction, you
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can see the irregularity of the blood vessel that was leading to the
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hemorrhage. Notice that the patient has necrosis in the adjacent soft tissue,
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this is air in the adjacent soft tissue of the tonsil secondary to
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the radiation necrosis. So very poor prognosis, not much to do here.
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Fortunately, this is not the internal carotid artery, this is the external
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carotid artery and that can be sacrificed quite readily.
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The other scenario where you have bleeding out from carotid injury may be
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from a penetrating wound. Here we have a patient who... Actually,
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this is a pen that was jabbed into the individual during an altercation,
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and you see that it's going across the soft tissues of the neck
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and actually is embedded in one of the thoracic vertebrae. Unfortunately,
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either from something like a pen or from bullet fragments,
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you may completely injure your carotid artery, be it the external or the
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internal carotid artery, which can lead to extravasation into the neck,
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another emergency that has to be dealt with as part of your head
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and neck neuroradiology experience. Here, for example, is the CTA. We have
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a carotid artery here. We actually don't see the carotid artery here.
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We don't see the carotid artery in the petrous internal carotid artery.
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That's because this has just been blown apart and some of this is
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bone fragment, some of this is metal fragment, but some of this is
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extravasation of contrast from the perforated, left internal carotid artery.
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Because this patient was having neck pain and a drop in the hematocrit,
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the patient was taken to evaluation with conventional arteriography. Here
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you can see the CTA reconstruction of the patient showing the carotid artery,
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the common carotid artery here, and then the stump of an internal carotid
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artery and then the irregularity of the external carotid artery branches.
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The patient went to conventional arteriography and because there was leakage
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of the external and internal carotid arteries, you see that they used extensive
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coiling. This is the metal from the bullet wounds
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and they occluded the internal carotid artery so that way it would not
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continue to bleed out. So this patient had both external as well as
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internal carotid artery source of the hemorrhage in the left side of the
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neck.
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