ARRS 2022 Abstracts

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E1267. Carotid Blow-out Syndrome: Interventional Radiologic Management - Preliminary Experience
Authors
  1. Jaime Tisnado; VCU Health System
Background
Carotid blowout syndrome (CBOS) is a catastrophic neurovascular emergency associated with a high morbidity and mortality. The main etiologic factors are: head and neck malignancies with tumor invasion; post-radiation therapy of malignancies; and less commonly, postoperative complications, inflammation, trauma, vasculitides, and collagen diseases, among others. The conventional surgical management (carotid artery and/or vertebral artery and/or branch ligation or bypass) is rather difficult and associated with significant morbidity and mortality and could be ineffective in controlling the situation. At this time, ideal management of this serious condition is endovascular, i.e., insertion of stents of different kinds (covered or uncovered, balloon expandable or self-expandable) and/or embolization of the carotid and/or vertebral arteries and/or branches, with temporary or permanent agents and occluding devices. Permanent or temporary success is expected with stent insertion and/or embolization, or both procedures combined. We have managed many patients, not considered ideal candidates for surgery, at least during the acute phase, with covered and uncovered stents from different manufacturers; we have embolized some patients and others have had both procedures combined. The procedures have been done in the interventional radiology suites by a team of interventional and neurointerventional radiologists and surgeons working in a collaborative rather than adversarial manner. No major complications related to the procedures have been found. The patients have had long-term or short-term improvement in their condition. The emergency management of CBOS by stenting and/or embolization or both is a safe, effective, and relatively easy procedure to temporarily manage these seriously ill patients. A longer follow-up and more patients are needed to determine the definitive role of stenting and/or embolization in CBOS. The conventional surgical management of CBOS may be difficult and/or ineffective; therefore, the endovascular management must be considered the first choice of therapy, at least for now, especially in clinically desperate situations.

Educational Goals / Teaching Points
This exhibit aims to present a succinct scope of the problem (CBOS) and to call the attention of radiologists and clinicians to this entity, which may be relatively more common than previously thought. We aim to make the readers aware of the role of the endovascular approach, rather than surgical management of this highly lethal entity, and we will present some interesting radiologic findings of CBOS during diagnostic imaging.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
CT is the ideal diagnostic modality. DSA is used usually during management rather than for diagnosis. Follow-up studies are important if one suspects CBOS and the disease may be in the beginning or impending stage.

Conclusion
CBOS is a serious condition that needs to be managed by endovascular methods. A high index of suspicion is needed by radiologists to diagnose this potentially lethal condition.