Abstract Introduction Carotid mycotic aneurysms represent a rare and challenging clinical entity. Carotid artery ligation is an accepted treatment option for aneurysms when reconstruction is not feasible. We present a case of successful management of a ruptured mycotic aneurysm with arterial ligation in an intravenous drug user. Case Presentation 34-year-old male with a history of intravenous drug use presented with one week of progressive neck pain, edema, and fever. CT revealed a 4x5x7 cm left-sided abscess encasing the left carotid bifurcation and pseudoaneurysm of the left common carotid artery (LCCA) along with multiple needle fragments. Patient was taken to the OR for an awake nasotracheal intubation and repair. Intraoperatively, an infected hematoma was evacuated, revealing a one-centimeter erosion of the posterior LCCA. Surgery was complicated by significant hemorrhage requiring emergent carotid ligation. Blood, tissue, and abscess cultures grew MRSA. On day 2, neurologic examination showed complete right-sided facial paralysis and 0/5 strength in the right upper and lower extremities, new since admission. CT head demonstrated a large left-sided middle cerebral artery ischemia, likely secondary to carotid ligation. On day 5 his neurological status improved with 4/5 strength on the right. Post-extubation, he was noted to have mild expressive and receptive aphasia, and coordination deficits. Fortunately, he continues to improve with therapy. Discussion Carotid artery mycotic aneurysm of the is rare, found in 0.03% in all arterial aneurysms, with trauma being the most common etiology (∼42%). Reconstructive surgery is preferred in carotid aneurysm repair with ligation carrying stroke risk of up to 29% in patients with non-traumatic etiology. Ligation is reserved for aneurysms that are not amenable to clipping or coiling, failed prior repair, mycotic or when collateral circulation is confirmed adequate. Neurological outcome data in this mycotic population is limited. However, a case series of 30 carotid ligations for aneurysms of various etiologies reported four transient symptoms, one persistent hemiparesis, and two deaths after internal carotid ligation, making the risk of stroke after carotid artery ligation lower in mycotic aneurysm compared to acute trauma. Tools for preoperative assessment of collateral circulation before carotid ligation are robust, but difficult to execute in an acute surgical setting. Surgical intervention is the treatment of choice for mycotic pseudoaneurysm. While various surgical therapies are available, ligation may be necessary when reconstruction is impossible. In non-traumatic settings, strong collateral supply through the Circle of Willis appears to limit the risk of stroke with carotid ligation. This abstract is funded by: None
Akunuri et al. (Fri,) studied this question.