1501 - "Under Pressure: The Unseen Threat of Carotid Blowout Syndrome"

Case Diagnosis: Carotid Blowout Syndrome

Case Description: A 65-year-old male with PMH of laryngeal cancer, previously treated with radiation therapy, presented to the emergency department with pulsatile bleeding from the left neck. He underwent carotid stenting for carotid blowout syndrome, likely a complication of his prior radiation treatment. The procedure was complicated by intraoperative occlusion of the internal carotid and left middle cerebral arteries, leading to ischemia. Subsequently, the patient developed right facial droop, dysphagia, cognitive deficits, and right upper extremity weakness, severely impairing his function. Following three weeks of intensive speech, occupational, and physical therapy in acute inpatient rehabilitation, the patient was discharged home.

Discussions: Carotid Blowout Syndrome (CBS) is a life-threatening emergency predominantly seen in patients with head and neck malignancies, especially those with a history of squamous cell carcinoma who have undergone radiation therapy.  Radiation is believed to compromise the structural integrity of the vasa vasorum in the carotid arteries, significantly increasing the risk of arterial wall rupture. CBS typically presents with symptoms such as nasal, oral, or peritracheal bleeding, with nearly half of the patients experiencing a sentinel bleed, which may initially be managed with manual pressure to achieve temporary hemostasis.

In this patient, who had recently undergone radiation therapy for laryngeal cancer and suffered a left MCA stroke secondary to CBS, the clinical approach was tailored to address specific complications. Therapy focused on managing dysphagia, ensuring adequate pain control, and conditioning to mitigate fatigue exacerbated by chemoradiation.

Conclusions: In managing patients with head and neck cancer, it is crucial to consider the sequelae of radiation treatment and other potential complications such as CBS, a condition that remains underrecognized in the physiatry community. These patients often require enhanced focus on dysphagia therapy and speech rehabilitation due to the anatomical and functional impairments associated with their cancer and its treatment.