Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology

IR PARA

ISSN-e 1984-8773

Volume 1 Number 3


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Case reports

External carotid artery aneurysm: a rare condition diagnosed in cosmetic consultation

Aneurisma da artéria carótida externa: uma condição rara diagnosticada durante uma consulta cosmética


Edileia Bagatin1, Karin V. Ferreira1, Marcos Docema1, Cristhine Leão1, Karime M. Hassun1, Erica de Oliveira Monteiro1, Sérgio Talarico1

PhD in Dermatology – Department of Dermatology, Universidade
Federal de São Paulo1, Master in Dermatology – Department of Dermatology,
Universidade Federal de São Paulo2, Master in Dermatology – Hospital Sírion-Libanês3, Master in Dermatology – Department of Dermatology, Universidade Federal de São Paulo4, Master in Dermatology – Department of Dermatology,
Universidade Federal de São Paulo2, Master in Dermatology – Department of Dermatology,
Universidade Federal de São Paulo2

 

Abstract

The aim of this report is to highlight and warn cosmetic dermatologists about the need of a complete and careful examination of any patient that looks for our evaluation, even when they ask only for cosmetic treatments and/or procedures. This is nowadays a very important concern as people and some physicians are involved in an exaggerated search for eternal beauty. This represents a very profitable practice for dermatologists and plastic surgeons. But we should never forget that a dermatologic consultation can be an opportunity to discover an unnoticed dermatosis or signs related to systemic diseases.

Keywords: ANEURYSM, CAROTID ARTERY, EXTERNAL, ESTHETICS

CASE REPORT

A 52-year-old woman, Fitzpatrick`s phototype classifi cation1 IV, was referred to the Cosmetic Dermatology Department, for treatment of acne scars and melasma. During the dermatological examination we noticed a facial asymmetry with subcutaneous augmentation in her left hemi-face. Our interpretation was a possible lymphedema related to previous severe infl ammatory acne or to a congenital deformity. We prescribed a 0,025% tretinoin and 4% hydroquinone cream and SPF 15 broad spectrum sunscreen for. After 30 days we started monthly application of superfi cial chemical peelings in order to prepare her skin for dermabrasion. During the treatment we noticed a progressive increase of her facial asymmetry, as well as a discrete bluish color and a light pulsation in the affected area. We also observed an evident venous lake on her left lower lip and one venous ecstasy on the left pre-auricular area (Figura 1).

We decided to stop the cosmetic treatment and to investigate any disease. Our fi rst hypothesis was an haemangioma. Doppler Ultrasonography, Magnetic Resonance Imaging (MRI) and Magnetic Resonance (MR)-Angiography were performed (Figuras 2 and 3). The diagnosis was an intra-parotid aneurysm of the external carotid artery that was causing a venous compression with edema and congestion.

She was then referred to the Vascular Surgery Department and she is now being prepared for surgical intervention.

DISCUSSION

Acne scars and melasma are common cosmetic problems that, as other severe dermatosis, can affect patients’ quality of life.2 It is well known that the effective treatment of acne and its scars has a positive impact on emotional and social aspects of the patients. 3,4,5 The approach towards acne scars requires the combination of topical and surgical treatments, depending on the scar type.6 We usually perform a first step for skin preparation, for 30 days, using tretinoin and hydroquinone creams at night, as well as sunscreen during the day. Then, as referred to in the literature, we use the following procedures in our routine:6,7 superficial pulse chemical peels, medium depth chemical peel, microdermabrasion, dermabrasion, soft tissue augmentation, subcision, punch elevation, punch excision and skin transplantation, surgical excision and laser resurfacing,8,9 according to the scar types,as well as intralesional infiltration with corticosteroids for the hypertrophic scars.

For our patient we prescribed tretinoin combined wtih hydroquinone and sunscreen, as this treatment would be beneficial for melasma as well as skin preparation for further procedures. We interrupted the treatment after five pulses of superficial chemical peels as soon as we suspected of a vascular disease.

The occurrence of an external carotid artery aneurysm,which is a very rare condition, was confirmed by MR-Angiography.

In our review of the literature we found a multicentric Serbian study10 about treatment options for extracranial carotid artery aneurysm. The authors reported 91 cases of this condition in 76 patients, among which 13 had bilateral involvement. There were 61 (80.3%) male and 15 (19.7%) female patients, with an average of 61.4 years of age. The majority (61 cases or 67%) of the aneurysms involved the internal carotid artery, 29 (31.9%) were localized in the common carotid artery bifurcation and only one (1.1%) in the external carotid artery. Twenty-nine (31.9%) of these cases were totally asymptomatic at the time of diagnosis.

The two most frequently reported causes of carotid artery aneurysms are degenerative atherosclerosis or trauma, like bone fracture, penetrating wound of the neck and other injuries.10,11,12,13 A revision study13 reported 386 patients with traumatic pseudo-aneurysms of the external carotid artery branches situated on the face and temples. Other etiologies are:10,11 previous carotid surgery, tuberculosis, arterial fibromuscular dysplasia, brucellosis, Behçet’s disease and neurofibromatosis.15 There are also cases of mycotic external carotid pseudoaneurysm related to Salmonella septicemia.16 Magnetic resonance angiography has been considered an efficient method, with high sensitivity and specificity, for the diagnosis of head and neck vascular diseases.17 For our patient it allowed a conclusive diagnosis.

The usual treatment for this condition is surgical resection of the aneurysm, followed by re-establishment of the carotid continuity or ligation between internal and external carotid artery. In general, there is no operative mortality or significant morbidity.11 Another approach is the endovascular stent graft implantation with obliteration of the carotid aneurysm. This is safer and less invasive than surgical repair.18

We present a very rare case of carotid artery aneurysm located in the external branch, occurring in a female patient and with unknown etiology. It was responsible for venous compression signs, like edema, lip venous lake, cutaneous venous ecstasy as well as visible asymmetry on the patient’s face.

Finally, we think that this report can be useful to illustrate why dermatologists, even during a consultation for cosmetic purposes, should always be provided a thorough history and physical examination.

References

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2 . Harlow D, Poyner T, Finlay AY, Dykes PJ. Impaired quality of life in adults with skin disease in primary care. Br J Dermatol 2000; 143:979-982

3 . Layton AM, Seukeran D, Cunliffe WJ. Scarred for life? Dermatology 1997; 195(Suppl 1):15-21

4 . Gollnick H, Cunliffe W, Berson D et al. Management of acne. A report from a global aaliance to improve outcomes in acne. J Am Acad Dermatol 2003; 49:S1-38

5 . Ng CH, Tam MM, Celi E, Tate B, Schweitzer I. Prospective study of depressive symptoms and quality of life in acne vulgaris patients treated with isotretinoin compared to antibiotic and topical therapy. Austr J Dermatol 2002; 45:262- 268

6 . Goodman GJ. Postacne scarring: a review of its pathophysiology and treatment. Dermatol Surg 2000; 26:857-871

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8 . Alster TS, West TB. Resurfacing of atrophic facial acne scars with a high-energy, pulsed carbon dioxide laser. Dermatol Surg 1999; 22:151-4; discussion 154-155

9 . Alster TS, McMeekin TO. Improvement of facial acne scars by the 585 nm flashalamp-pumped pulsed dye laser. J Am Acad Dermatol 1999; 35:79-81

10 . Radak D, Davidovic L, Vukobratov V et al. Carotid artery aneurysms: Serbian multicentric study. Ann Vasc Surg 2007; 21:23-29

11 . da Gama AD, Rosa A, Martins C et al. Primary aneurysms of carotid bifurcation: surgical management. Rev Port Cir Cardiotorac Vasc 2005; 12:163-168

12 . Papavassiliou V, Liapis C, Kakissis J, Safioleas M, Kaperonis E, Gogas J. Aneurysms of the distal branches of the external carotid artery. Vasa 2000; 29:87-88

13 . Campbell AS, Butler AP, Grandas OH. A case of external carotid artery pseudoaneurysm from hyoid bone fracture. Am Surg 2003; 69:534-535

14 . Conner WC, Rohrich RJ, Pollock RA. Traumatic aneurysms of the face and temple: a patient report and literature review, 1644 to 1998. Ann Plast Surg 1998; 41:321-326

15 . Smith BL, Munschauer CE, Diamond N, Rivera F. Ruptured internal carotid aneurysm resulting from neurofibromatosis: treatment with intraluminal stent graft. J Vasc Surg 2000, 32:824-828

16 . Nader R, Mohr G, Sheiner NM, Tampieri D, Mendelson J, Albrecht S. Mycotic aneurysm of the carotid bifurcation in the neck: case report and review of the literature. Neurosurgery 2001; 48(5):1152-1156

17 . Tiutin LA, Iakovleva EK. Magnetic resonance angiography in diagnosis of head and neck vessels diseases. Vestn Rentgenol Radiol 1998; 6:4-9

18 . Mukherjee D, Roffi M, Yadav JS. Endovascular treatment of carotid artery aneurysms with stent grafts. J Invasive Cardiol 2002; 14:269-272


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