Abstract
Abstract Background: Cervical hematomas can lead to airway compromise, a life threatening condition, regardless of the cause. The following case is the first presentation of cervical hematoma as a complication of endovascular treatment of middle cerebral artery aneurysm. Case report: A 49 year-old woman was scheduled for stent placement under general anesthesia for middle cerebral artery aneurysm. Few days before intervention, acetyl salicylic acid and clopidogrel treatment was started. Following standard monitoring and anesthesia induction, the patient's trachea was intubated with a 7.5 mm endotracheal tube and the procedure was completed without any complications. Three hours later, dyspnea developed and physical examination revealed progressive swelling and stiffness in the neck. Endotracheal intubation was performed with a 6 mm diameter uncuffed tube with the aid of sedation. The vocal cords were completely closed due to compression. There was no leak around the endotracheal tube. The rapidly performed computerized tomography scans showed an enormous hematoma around the neck and extravasation of contrast medium through superior thyroid artery. After coil embolization of superior thyroid artery, she was taken to the intensive care unit as intubated and sedated. Surgical exploration of the hematoma was not recommended by the surgeons, because she was on clopidogrel. After two days, the patient's trachea was extubated safely ensuring that the swelling was sufficiently ceased and leak detected around the endotracheal tube. Conclusions: Securing the airway rapidly by endotracheal intubation is the most crucial point in the management of cervical hematomas. Diagnostic and therapeutic procedures should be performed only afterwards.
Keywords
Superior thyroid artery, Cervical hemorrhage, Airway obstruction, Aneurysm endovascular treatment
Resumo
Resumo Justificativa: Hematomas cervicais podem levar ao comprometimento das vias aéreas, uma condição de risco para a vida, independentemente da causa. O presente caso é a primeira apresentação de hematoma cervical como uma complicação do tratamento endovascular de aneurisma da artéria cerebral média. Relato de caso: Uma mulher de 49 anos foi agendada para a colocação do stent sob anestesia geral para aneurisma da artéria cerebral média. Poucos dias antes da intervenção, um tratamento com ácido acetilsalicílico e clopidogrel foi iniciado. Após a indução da anestesia e o monitoramento padrão, a traqueia da paciente foi intubada com um tubo endotraqueal de 7,5 mm e o procedimento foi concluído sem quaisquer complicações. Três horas mais tarde, a paciente desenvolveu dispneia e o exame físico revelou edema progressivo e rigidez do pescoço. A intubação endotraqueal foi feita com um tubo de calibre 6 mm sem balonete com o auxílio de sedação. As pregas vocais estavam completamente fechadas devido à compressão. Não houve vazamento ao redor do tubo endotraqueal. Tomografias computadorizadas feitas rapidamente mostraram um enorme hematoma no pescoço e extravasamento do meio de contraste através da artéria tireoidiana superior (ATS). Após embolização com molas da ATS, a paciente foi levada para a unidade de terapia intensiva intubada e sedada. A exploração cirúrgica do hematoma não foi recomendada pelos cirurgiões porque a paciente tomava clopidogrel. Depois de dois dias, a traqueia da paciente foi extubada com segurança. Isso garantiu que o edema havia cessado o suficiente e o vazamento detectado ao redor do tubo endotraqueal também. Conclusões: Proteger as vias aéreas rapidamente por meio de intubação endotraqueal é a conduta mais crucial no manejo de hematomas cervicais. Os procedimentos diagnósticos e terapêuticos devem ser feitos somente após essa conduta.
Palavras-chave
Artéria tireoidea superior, Hemorragia cervical, Obstrução das vias aéreas, Tratamento endovascular de aneurisma
References
Stenner M, Helmstaedter V, Spuentrup E. Cervical hemorrhage due to spontaneous rupture of the superior thyroid artery: case report and review of the literature. Head Neck. 2010;32:1277-81.
DiFrancesco RC, Escamilla JS, Sennes LU. Spontaneous cervical hematoma: a report of two cases. Ear Nose Throat J. 1999;78(168):171-5.
Jang EW, Kim YB, Chung J. Clinical risk factors affecting procedure-related major neurological complications in unruptured intracranial aneurysms. Yonsei Med J. 2015;56:987-92.
Coil embolization for intracranial aneurysms: an evidence-based analysis. Ont Health Technol Assess Ser. 2006;6:1-114.
Tew JM, Mayfield FH. Complications of surgery of the anterior cervical spine. Clin Neurosurg. 1976;23:424-34.
Boyce JR, Peters GE. Complete vasomotor collapse: an unusual manifestation of the carotid sinus reflex. Anesthesiology. 2003;98:1285-7.
Sethi R, Tandon MS, Ganjoo P. Neck hematoma causing acute airway and hemodynamic compromise after anterior cervical spine surgery. J Neurosurg Anesthesiol. 2008;20:69-70.
Yu NH, Jahng TA, Kim CH. Life threatening late hemorrhage due to superior thyroid artery dissection after anterior cervical discectomy and fusion. Spine. 2010;35:739-42.
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