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LETTER TO EDITOR Table of Contents   
Year : 2001  |  Volume : 11  |  Issue : 4  |  Page : 218-220
Vertebral artery pseudoaneurysm : A rare complication of transoral needle aspiration of retropharyngeal abscess


15A/14,East Patel Nagar, New Delhi-110008, India

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How to cite this article:
Puri S K, Narang P, Singh D, Panigrahi P, Gupta S. Vertebral artery pseudoaneurysm : A rare complication of transoral needle aspiration of retropharyngeal abscess. Indian J Radiol Imaging 2001;11:218-20

How to cite this URL:
Puri S K, Narang P, Singh D, Panigrahi P, Gupta S. Vertebral artery pseudoaneurysm : A rare complication of transoral needle aspiration of retropharyngeal abscess. Indian J Radiol Imaging [serial online] 2001 [cited 2019 Nov 22];11:218-20. Available from: http://www.ijri.org/text.asp?2001/11/4/218/28409
Sir,

Pseudoaneurysms of extra-cranial vertebral artery are rare and usually occur after penetrating trauma or more rarely, after blunt trauma [1]. We wish to report a case of iatrogenic vertebral arteries pseudoaneurysm caused by repeated attempts to drain a retropharyngeal abscess.

A twelve-year-old boy presented with a swelling in the right upper neck, which had been gradually increasing in size during the last one month. Two weeks earlier, he had undergone a trans-oral aspiration of an acute pyogenic retropharyngeal abscess elsewhere, when about 20 ml of pus mixed with blood was aspirated after two initial unsuccessful attempts. Pus was sterile on culture. There was no evidence of tuberculosis.

On examination, there was a pulsatile non-tender swelling in the right upper neck in the posterior triangle. There was no sign of inflammation or visible veins over the swelling and a systolic bruit could be heard over the swelling. Carotid pulsation could be felt normally on both sides. On compression of the ipsilateral carotid artery the bruit in the swelling persisted. Rest of the general physical examination and neurological examination was unremarkable. Routine blood examination was within normal limits.

Color Doppler imaging reveled an echoic lesion measuring 2.7 x 2.3 x 1.9cm in size with an echogenic rim in the periphery and located in upper posterior triangle deep to the muscles. Swirls of moving blood were seen on jet of high velocity. The blood could be easily located arising from the vertebral artery posteriorly, representing the neck of the aneurysm. The internal jugular vein and the external and internal carotid arteries were seen separately and showed normal blood flow [Figure - 1]a,b.

Transfemoral selective right vertebral angiogram showed an oblong aneurysm arising from the distal vertebral artery at the level of C2 and projecting laterally. Beyond the aneurysm, the artery was not filling [Figure - 2]. A left vertebral angiogram showed good filling of basilar artery, both posterior cerebral arteries and other main branches. No retrograde filling of right vertebral artery or the aneurysm was noticed. Two 3mm, steel coils were introduced in the distal vertebral artery just proximal to the aneurysm and the artery was completely occluded with no filling of aneurysm on check angiogram. Since the artery distal to the aneurysm, could not be entered and a contra-lateral check angiogram demonstrated no filling of the ipsilateral vertebral artery, occlusion of the ipsilateral artery proximal to the aneurysm now showed an echogenic thrombus [Figure - 3]

Pseudoaneurysm formation resulting from trauma is far more common in carotid arteries as compared to vertebral arteries. This is because of the relatively unprotected location of the carotid arteries in the soft tissues of the neck. The vertebral arteries are protected, coursing within the bony canal formed by the foramina transversaria of the cervical vertebrae. In a study of arterial injuries among civilians, vertebral artery injuries accounted for only 0.5% of all arterial injuries [2]. Besides penetrating or blunt trauma to neck another form of trauma that can lead to vertebral artery injury and pseudoaneurysm formation, is iatrogenic trauma. Various procedures that have been reported to cause vertebral artery injuries are percutaneous jugular vein catheterization, subclavian arteriography and chiropractic manipulation of neck [3],[4],[5]. However, to the best of our knowledge, this is the first case report of a vertebral artery pseudoaneurysm formation following trans-oral aspiration of a retropharyngeal abscess.

Angiography still is the gold standard for demonstrating the exact anatomical location of the neck of the aneurysm and for therapeutic planning. Color Doppler imaging, spiral 3D CT angiography and MR angiography are all very useful non-invasive imaging modalities. Amongst these, Color Doppler imaging is most easily available and can quickly diagnose aneurysms in the neck. A swirling pattern of blood flow seen throughout the cardiac cycle and a "to-and-fro" spectral waveform seen at the neck of pseudoaneurysm are classical signs [2]. The neck of the aneurysm can easily be located by identifying the high velocity jet of blood flow.

Two therapeutic options available for treating such aneurysms are the surgical or percutaneous transfemoral approach to occlude the ipsilateral artery provided there is adequate blood flow to the posterior circulation by the contralateral vertebral artery. In case of aneurysms arising from the distal vertebral artery near the foramen magnum, surgical access is generally difficult and hence a transfemoral approach, which is distinctly safer, is the preferred mode of treatment. Balloon occlusive devices or intra-luminal coils can be deployed to occlude the artery.

Occlusion of the artery proximal as well as distal to the neck of the aneurysm is desirable to avoid the risk of refilling of the aneurysm from the contralateral side. However, in our patient, since the artery distal to the aneurysm could not be entered and a check contra-lateral vertebral angiogram did not show any filling of the ipsilateral artery distal to the aneurysm, occlusion of the artery proximal to the aneurysm only, was considered sufficient.

 
   References Top

1.Wiener I, Flye MW. Traumatic false aneurysm of the vertebral artery. J Trauma 1984; 24: 346 - 349   Back to cited text no. 1  [PUBMED]  
2.Wilkinson DL, Polak JF, Grassi CJ, Whittemore AD and O'n Leary DH. Pseudoaneurysm of the verebral artery: appearance on Colour Flow Doppler Sonography. AJR 1988; 151:1051-1052   Back to cited text no. 2    
3.Amaral JF, Grigoriev VE, Darfam GS and Carney WI. Vertebral artery pseudoaneurysm: a rare complication of subclavian artery catheterization. Arch Surg 1990; 125:546-547  Back to cited text no. 3    
4.Aoki H, Mizobe T, Nozuchi S, Hatanaka T and Tanaka Y. Vertebral artery pseudoaneurysm: a rare complication of internal jugular vein catheterization. Anesth Analg 1992; 75: 296-298   Back to cited text no. 4    
5.Davidson KC, Weiford EC, Dixon GD. Traumatic vertebral artery Pseudoaneurysm following chiropractic manipulation. Radiology 1975; 115 : 651-652   Back to cited text no. 5    

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S K Puri
15A/14,East Patel Nagar, New Delhi-110008
India
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