Interventional Neuroradiology 17: 386-390, 2011 www.centauro.it

Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting A Case Report

A. tSuRuMI4, Y. tSuRuMI2, M. NEgORO3, K. YOKOYAMA4, M. OHEdA4, N. SuSAKI4, S. tSugANE4, t. tAKAHASHI4, S. MIYACHI1 1 Nagoya University Graduate School of Medicine; Nagoya, Japan 2 Department of Neurosurgery, Japanese Red Cross Nagoya Daiichi Hospital; Nagoya, Japan 3 Department of Neurosurgery, Fujita Health University; Toyoake, Japan 4 Department of Neurosurgery, National Hospital Organization Nagoya Medical Center; Nagoya, Japan

Key words: carotid artery stenting, cervical hemorrhage, manual compression

Summary therapy are administered during the periproc- edural period of CAS, there is a tendency for We describe a patient with subcutaneous he- hematomas to enlarge dramatically should he- matoma associated with manual cervical mas- morrhage occur. Reported causes of cervical sage during carotid artery stenting. hematoma include arterial perforation by the A 73-year-old man with left cervical carotid guide wire during the procedure and vessel artery presented with left amaurosis fu- rupture due to over-inflation of the percutane- gax. We performed carotid artery stenting using ous transluminal (PtA) balloon 2,3. distal embolic protection with balloon occlu- to the best of our knowledge, the literature sion. Dual antiplatelet therapy was maintained contains no reports of manual compression of in the periprocedural period and an anticoagu- the cervical region 4 causing the formation of a lant agent was administered during the proce- cervical subcutaneous hematoma, as the au- dure. Because the aspiration catheter became thors experienced. the authors report the entrapped by the , it did not reach the distal present case because cervical hematoma is a side of the stenotic lesion, and manual compres- complication that can have a detrimental effect sion of the cervical region was therefore per- on prognosis due to compression of the tra- formed. Immediately afterwards, a subcutaneous chea, causing dyspnea. hemorrhage occurred in the cervical region. There was no postoperative dyspnea due to en- largement of the hematoma, which was absorbed Case Report spontaneously. Cervical subcutaneous hematoma can occur History in the cervical region due to cervical massage in patients who are receiving adjuvant antiplatelet this 73-year-old man presented with left therapy and anticoagulation therapy. amaurosis fugax. He was examined in the de- partment of Neurology, where left cervical ca- rotid artery stenosis was identified by magnetic Introduction resonance (MRA) and carotid ul- trasonography, and he was referred to the de- Cervical subcutaneous hematoma is a rare partment of Neurosurgery in May 2009. the pa- complication of carotid artery stenting (CAS) 1. tient was started on oral clopidogrel (75 mg once Because dual antiplatelet and anticoagulant daily) and aspirin (100 mg once daily), which was

386 A. Tsurumi Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting

↑ Figure 2 the left cervical area immediately after the pro- cedure. Immediately after manual compression of the neck, the patient complained of pain in the left cervical area, and a hematoma was observed.

← Figure 1 Left common carotid artery angiography (lat- eral view) before stenting showing a 70% stenosis at the origin of the left internal carotid artery.

maintained during the perioperative period. Re- Carotid Artery Stenting Procedure and Post sidual platelet reactivity measured by the veri- Treatment Course fyNow Assay (Accumetrics Inc., ,San diego CA, uSA) was 481 Aspirin Reaction units for aspi- Local anesthesia was administered to the pa- rin and 109 P2Y12 Reaction units for clopidog- tient. We then intravenously administered 4000 rel, respectively; these results indicated that both units of heparin to achieve an activated coagula- antiplatelet agents were at therapeutic levels. tion time of 258 s. A 90-cm 6-french guide sheath (Shuttle-SL; Cook Medical, Blooming- ton, IN, uSA) was inserted into the right radial Examination artery and advanced until its tip reached the left On admission, the patient had no neurologi- common carotid artery by means of a coaxial cal deficit. Brain magnetic resonance imaging system. A 125-cm 4-french catheter (Cerulean showed no cerebral infarction. Cervical MRA g; Medikit, tokyo, Japan) and an angled demonstrated severe stenosis of the left cervi- 0.035-inch hydrophilic guidewire (Radifocus cal carotid artery. Carotid ultrasonography also guide wire M; terumo, tokyo, Japan) were in- revealed severe stenosis of the left cervical ca- serted into the 6-french guide sheath by means rotid artery, with hypoechoic plaque and calci- of the coaxial system, enabling easy insertion of fication. Left common carotid angiography in- the tip of the sheath as far as the left common dicated 70% stenosis of the left cervical carotid carotid artery. there was no arterial penetration artery according to North American Sympto- by the wire or catheter. using a roadmap, a Per- matic Carotid trial 5 (NAS- cuSurge guardWire (Medtronic, Minneapolis, CEt) Criteria (figure 1). Right common ca- MN, uSA) was advanced into the distal cervical rotid angiography demonstrated a 70% steno- internal carotid artery. After distal embolic pro- sis of the petrous portion of the right internal tection with balloon occlusion, balloon angi- carotid artery. indicated that the oplasty with a 4×40-mm Sterling balloon (Bos- left common carotid artery originated from the ton Scientific, Natick, MA, uSA) (inflated to 6 brachiocephalic artery. atm/30 s) resulted in suboptimal recanalization,

387 Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting A. Tsurumi

therefore a 10×40-mm Precise carotid stent clude arterial perforation by the guide wire (Cordis, Miami Lakes, fL, uSA) was advanced and rupture of the carotid artery due to over- over the wire and deployed across the stenotic inflation of the PtA balloon 2,3. In all such re- lesion in the internal and common carotid arter- ports, the cause has been arterial hemorrhage ies. the residual stenosis was treated by tempo- resulting in marked enlargement of the he- rary inflation of a 5×20-mm Sterling balloon (in- matoma, compressing the trachea and requir- flated to 6 atm/15 s) in the waist (residual steno- ing endotracheal intubation. Arterial hemor- sis) of the stented lesion. When an aspiration rhage in the cervical region is a life-threaten- catheter (Eliminate; terumo) was then advanced ing complication. Once the arterial perforation to the vicinity of the PercuSurge guardWire occurs and the extravasation of the contrast balloon, its tip caught on the strut of the Precise medium can be visualized, the patency of the stent and could not be advanced further. Meas- airway must be immediately confirmed. Selec- ures such as swallowing saliva, turning the head tive embolization of the ruptured artery is ef- to the right and left, and inserting the 0.035-in fective for hemostasis. A covered stent can be guide wire into the aspiration lumen of the used for a laceration of the carotid artery. In Eliminate catheter were ineffective, and the patients who are given heparin, protamine sul- Eliminate catheter could only be advanced to fate can be administered to reverse heparin the vicinity of the PercuSurge guardWire bal- anticoagulation. loon after manual compression of the left cervi- In the case we describe, the subcutaneous he- cal region to change the direction of the internal matoma formed because of manual compres- carotid artery. sion of the neck and cervical massage, a differ- dispersed plague and blood were aspirated e