Idiopathic multiple aneurysm of external carotid artery.

Aneurysms of external carotid artery are rare. Treatments for these are undertaken for the prevention of complications like hemorrhage or rupture, and embolism. We present a 71-year-old male with idiopathic multiple aneurysm for the past 34 years on conservative management and regular follow up for the past 4 years. This case was discussed for the rarity of idiopathic multiple aneurysm of the external carotid artery and the need for individualized treatment protocol to be followed as in this case, only watchful observation considering the age and patient compliance. In this world of evolving surgical techniques and newer treatment modalities, conservative treatment still has a role to play. Primary care physicians at the community level have a major role in following these patients and referring them as and when the need arises.

Introduction

Carotid artery aneurysm are rare. Etiologies include injury, tumor of head and neck and rasiation therapy. These lesions though may cause life threatening hemorrhage, watchful observation is still considered as a treatment option in these patients.

Case Report

A 71-year-old male presented with pulsatile swelling over the right side of face and over the forehead in october 2009. The swelling has been there for the past 34 years. Patient denies history of trauma, transient ischemic attack, headache, or giddiness. Patient is a known diabetic and hypertensive for the past 9 years on regular medications.

Patient was evaluated with computed tomography (CT) angiogram, which showed aneurysm of the external carotid artery with thrombus within and multiple aneurysm of the branches of external carotid arteries.

Treatment[1] option of excising the aneurysm with ligation of external carotid aneurismal branches was discussed with the patient. Since the swelling was asymptomatic for the past 34 years, patient was not willing for any procedure.[2345]

The patient has been advised to come for regular follow up every 6 months. He is assessed with clinical examination on each visit and ultrasound examination performed once in a year to assess the size of the aneurysm.

The patient has been on follow up for the past 4 years without any new symptoms or increase in size of the aneurysm.

Discussion

Aneurysm of the external carotid artery and its branches have been described in cases due to trauma, iatrogenic injury, dental extraction, and also due to head and neck cancer because of tumor infiltration or due to radiation therapy.[2]

Geriatric patients with aneurysm are first consulted by a primary care physician and hence primary care physician at the community level has a major role in following these patients and referring these patients to specialized vascular centre. Increase in size of the aneurysm or impending rupture necessitates the need for referral to specialized center. The need for surgical intervention or endovascular stenting does not arise in our patient who has this aneurysm for 34 years and was on follow up for the past 4 years without any symptoms [Figure 1].

Figure 1

Pulsatile swelling over the face, forehead, and scalp

In this setting, the role of primary care physician is important to decide upon surgical or conservative management after having discussion with the patient. Conservative management[6] can be offered as treatment in such cases [Figure 2].

Figure 2

Multiple aneurysm of external carotid artery

This case was discussed for the rarity of idiopathic multiple aneurysm [Figure 3] of the external carotid artery [Figure 4] and the need for individualized treatment protocol to be followed, as in this case, only watchful observation.[6] In this world of evolving surgical techniques and newer treatment[234] modalities, conservative treatment still has a role to play.

Figure 3

Aneurysm of the branches of external carotid artery

Figure 4

Cross section showing thrombus within the aneurysm

Conclusion

Even in the era of advanced medical technology[345] practices, treatment should be individualized and the choice rests with the patient. Primary care physicians have a major role in follow up of these patients and decide upon referring these patients to specialized vascular center thus lessen the burden of vascular centre in following these patients.