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We report here the management of an acquired left carotid-jugular fistula in a 29-year-old man. This patient was referred to us for a ballistic wound of the left cheek evolving since one month with the diagnosis of a carotid pseudo-aneurysm discovered on Doppler ultrasound. The clinical presentation was marked by cervical thrill in favor of an arteriovenous fistula confirmed by computed tomography angiography. The surgical exploration by cervicotomy revealed a communication between common carotid artery and internal jugular vein that were repaired using a saphenous vein patch and a lateral suture respectively without complication. The control at five months found an asymptomatic patient with good patency of the repaired vessels.

The neck, being not protected by skeleton, is vulnerable to external trauma and injury which can involve blood vessels, muscles, nerves, and trachea. Carotid injuries can be potentially life-threatening by hemorrhage and stroke. We present a case of a 26-year-old manual worker who presented a neck injury caused by a metallic projectile. The injury involved the right common carotid artery with an internal jugular vein fistula, and tracheal damage. The patient was managed with surgical repair of the tracheal lesion, reconstruction of the carotid section using a PTFE graft bypass, and ligation of the internal jugular vein. In the immediate postoperative period, the patient presented with no neurological deficits, but he did develop a pulmonary infection that resolved with antibiotic therapy. The follow-up is now 3months. The patient is doing well without any neurological disorder.

La plaie carotidienne lors du cathétérisme jugulaire veineux est un accident rare mais pouvant être dramatique. Nous rapportons un cas d'hématome cervical compressif avec hémothorax survenu à la suite d'une plaie de l'artère carotide commune au décours d'un cathétérisme veineux jugulaire interne. Le diagnostic et la prise en charge de ce type de complication sont discutés.

Cervical artery dissection is rare in the neonatal period and is most often caused by birth injury during dystocic labor. The severity of this pathology is due to the possibility of serious neurological complications. We report a case of a male newborn who was born vaginally after shoulder dystocia. The extraction was difficult, resulting in a fracture of the right humerus. On the second day of life, the child presented generalized clonic convulsions. Computed tomography of the brain showed an ischemic stroke in the territory of the right middle cerebral artery, the territory of the right posterior cerebral artery, and the right lenticulostriate and capsular regions. Doppler ultrasonography and magnetic resonance angiography showed bilateral carotid artery thrombosis and dissection at the left common carotid artery and its two branches and the right vertebral artery. We discuss the mechanisms of this pathology and we emphasize preventive measures.

Aneurysm of the extracranial carotid artery is rare. The embolic risk mandates prompt intervention once diagnosed. The aim of this study was to determine therapeutic techniques, their indications and outcomes.We report a series of ten patients who underwent surgery for extracranial carotid artery aneurysm in the cardiovascular surgery department of La Rabta hospital.There were six men and four women, mean age 43 years. All patients were symptomatic (swelling and pulsatile cervical mass). Two patients had dysphonia and one patient underwent an emergency procedure because of aneurismal rupture. Aneurismal excision was performed in most patients. The arterial reconstruction was performed by end-to-end anastomosis in four cases, interposition of an autologous venous graft in four, interposition of a prosthetic graft in one and suture of a small rent in the artery in one. There was no postoperative mortality. Early postoperative morbidity included one recurrent laryngeal nerve injury, one hypoglossal nerve injury, one stroke and one infection with thrombosis of a prosthetic graft. The follow-up was uneventful.Surgical treatment of extracranial carotid aneurysms is required, in most cases with good results. Endovascular treatment may be an effective therapy in selected cases.

A surgical and anatomic approach to the skull base using the transmaxillary route is presented. This route is well-known and used for a long time for sinus conditions.This study was performed on injected cadavers. This study describes step by step this approach in microsurgical conditions following a vital lead: the infraorbital nerve.Anatomical landmarks are located in order to avoid complications. These complications are on one hand, hemorrhages by vascular lesions and on the other, definitive nerve palsy.Several skull base approaches exist, transfacial routes produce cosmetic damages. This route preserves the functional anatomy of the nose because it preserves the integrity of the lateral wall of the nasal cavity.

Behçet's disease is a multi systemic vasculitis of unknown origin characterized by recurrent oral and genital ulcerations, uveitis and skin lesions. Vascular involvement mainly interesting the venous system is present in about 7 to 38% of patients. Arterial involvement is present in 2 to 8% of patients and is associated with a high mortality. It may present as aneurysms, pseudo aneurysms or arterial occlusions. Pseudo aneurysm formation has been reported to be sometimes due to invasive imaging techniques, it may also follow arterial repair. We report two exceptional localizations of iatrogenic pseudo aneurysms due to accidental arterial puncture, involving respectively the internal carotid artery and the humeral artery. We discuss the clinical characteristics and therapeutic modalities of this complication.

Despite recent advances in automobile safety, facial trauma remains a common event. Cranio-facial trauma, which usually occurs within a context of multiple trauma, can, in some patients, lead to serious life-threatening vascular complications. Such injury usually involves the carotid system (hemorrhage, aneurysm, dissection). Management of these vascular injuries must be given the same priority as other multiple trauma injuries. We present few typical cases illustrating carotid-cavernous or vertebro-vertebral fistulae, false aneurysms, arterial dissections or oro-facial bleeding. Bleeding is generally controlled by ligation or compression, other lesions being diagnosed secondarily by arteriography depending on the particular clinical situation. Treatment may involve endovascular procedures to achieve intravascular embolism or vascular occlusion.

A 20-year-old man presented with mild intracranial bleeding, a Horner's syndrome, and left neck swelling following head injury. Following noncontrast CT of the brain, a contrast-enhanced helical CT was performed through the neck that showed a hematoma in the poststyloid space (carotid sheath) with irregular diameter of the ICA. Selective digital subtraction angiography confirmed the presence of left cervical ICA dissection with pseudoaneurysm formation. The aneurysm was resected and an end-to-end anastomosis was done using an inverted saphenous graft. Histology confirmed a diagnosis of traumatic ICA dissection with pseudoaneurysm formation and there was no evidence of pre-existing pathology. Helical CT is a simple, widely available, and relatively non-invasive imaging technique that correlates well with angiography. It should be considered in the evaluation of patients with suspected cervical ICA dissection.

We report a case of post-traumatic carotid artery dissection revealed by a painless Horner's syndrome. Horner's syndrome is a neurologic emergency when it appears rapidly, spontaneously or after a trauma. Each painful Horner's syndrome must be considered as due to a homonymous carotid artery dissection until proven otherwise. One must be attentive especially because the pain may be an inconstant finding and the Horner's syndrome incomplete. Ophthalmologists must be aware of this entity because they are the first and often only practicians to be consulted. They must consider the diagnosis, ask for an immediate MRI or angio-scan, start the treatment and assume the follow-up.

The standard internal jugular vein access is an anatomical-landmark method and the individual variations causes technical difficulty and sometimes morbidity. Ultrasound guidance for percutaneous puncture of internal jugular vein is used in 20 patients for hemodialysis catheter insertion. This method allow the visualization of jugular permeability and needle progression during puncture. A control historical group comparison emphasized the advantage of this technique with lower access time (20 s vs 90 s), more first needle pass success (90% vs 50%) and reduced morbidity (carotid puncture, hematomas). The ultrasound guidance is very simple and safe but major disadvantage is the cost of the equipment.

Thirteen patients treated for 14 arterial lesions of the supra-aortic trunks from blunt trauma between 1985 and 1993 were retrospectively reviewed. In 2 cases, the lesion was on the innominate artery, in 1 case on the right common carotid artery and in 11 cases on the subclavian artery. It consisted of rupture in 8 cases, pseudoaneurysm in 5 and occlusion from an intimal flap in 1 case. Acute ischemia of the upper limb was present in 5 patients, and severe local hemorrhage in 1 patient. Four patients (5 lesions) did not have symptoms on initial hospitalization. Two later suffered embolisms from a pseudoaneurysm with a fatal outcome from massive cerebral ischemia in one case. Eleven arteries were repaired and two were ligated because of massive associated soft tissue destruction of the shoulder and the arm requiring immediate amputation. In addition to these two amputations, a brachial plexus injury remained disabling for 4 other patients. Blunt injuries of the supra-aortic arterial trunks constitute an immediate challenge in the case of active bleeding and often require combined mediastinal or thoracic and cervical exposure. They carry a heavy morbidity when the subclavian artery is involved due to associated soft tissue or brachial plexus damage. Occult lesions of the arteries supplying the brain are dangerous because of the risk of interference with cerebral blood flow. They should be actively investigated and, if the distal part of the lesion is accessible, they should be treated surgically.

The authors use a series of 5 treated carotid wounds to identify the characteristics of these lesions and their management. The gravity of carotid wounds is due to the risk of hemorrhage as well as that of respiratory distress and secondary neurological deficit. Controversy persists regarding the legitimacy of revascularisation procedures in the presence of neurological lesions and, according to the majority of authors, such an approach is recommended unless the patient is in coma.

Carotid-cavernous fistulas are unusual complications of facial traumas but this life-threatening complication requires a rapid diagnosis. Noninvasive procedures as ultrasounds will confirm the diagnosis and are helpful to demonstrate hemodynamic conditions of the fistula. Angiography remains the main radiologic examination and embolization is now the preferred method of treatment. Surgical treatment will only be required after failure of the interventional radiology.

A case is reported of a patient with a traumatic aneurysm of the intracranial part of the carotid artery occurring after a traffic accident. The patient was admitted in coma (Glasgow score 5), and presented with a depressed fracture of the frontal and parietal bones, a fracture of the left petrous pyramid and of the left anterior clinoid process, as well as of the right tympanic bone and temporomandibular joint. The borders of the left carotid canal seemed unaltered. Despite the lack of localised neurological signs, cervical and transcranial Doppler ultrasonography was carried out. Intracranial carotid blood flow was found to be altered on both sides. Angiography showed a false carotid aneurysm on the left side (carotid siphon portion C3), and a moderate irregular stenosis of the C2 part on the right. There were no brain lesions on the CT scan. Prophylactic treatment with heparin was started. The patient recovered normal consciousness within a fortnight. The false aneurysm increased in volume and was treated by embolisation. Flow speeds in the carotid siphons also returned to normal. The usefulness of routine screening of patients with petrous bone fractures with Doppler ultrasound is discussed.

The authors present a typical case of a traumatic internal carotid aneurysm rupture appearing 40 years after a blunt head trauma and surgically treated with success. The etiopathogenic and clinical aspects are reviewed and the important place of the angiography in diagnostic and therapeutical strategy is discussed.

The authors report 3 cases of trauma induced false aneurysm (internal maxillary, external carotid and internal subpetrous carotid arteries) associated to closed mandibular fractures. These rare vascular complications of ill-defined pathogeny are often due to high speed facial impact. Clinical presentation is polymorphous (pseudo-parotidis, neurological deficit) and arteriography is the main step of the paraclinic investigation. The treatment essentially depend upon both the location and the evolutivity of the false aneurysm.

A series of 26 cases of injury to the extracranial carotid artery included 3 patients with false aneurysms, 21 dissecting aneurysms, and 3 aneurysms following direct trauma. Clinical and angiographic findings, and clinical course in the 26 patients are described, together with changes observed on angiography in the 11 cases where this was repeated. Prognosis in this series appeared to be better than that usually described.

The authors describe two cases of post-traumatic aneurysms of the intracavernous carotid artery. They analyze the difficulties they have encountered during direct approach. Direct cure was impossible for the first patient because of the arterial wall dilaceration. In the second case, the aneurysm has been treated upon by stitching. A second operation with injection of biological glue into the cavernous sinus was required because of the secondary formation of a carotido-cavernous fistula in front of a second metal fragment.

Thanks to analysis of 46 observations and the review of the literature, the authors enumerate the main physiopathological mechanisms of this uncommon entity with its ambiguous clinical aspects and it too often severe evolution. They bring some new elements of the prognosis and emphasize the necessity of a rational utilization of neuroradiological investigations in order to avoid some diagnostic traps and purpose the better treatment of which indications are analysed and censured. Extra-intracranial by-pass represents a new therapeutic advance which will perhaps improve the prognosis of this condition.

The increasing practice of small arteries anastomosis especially in neurosurgery entails improvements in suture techniques. Classical suture is slow and needs a prolonged clamping. The stitches are responsible for severe necrotic lesions in the arterial wall. A biological glue made of cryoprecipitated human fibrinogen, factor XIII and fibronectin, locally activated by thrombin, is tested here on rabbit's common carotid. The application of the glue on intact or sectioned arteries appears innocuous, notably with regard to its thrombogenic potential. Comparison of classical sutures and sutures with glue and a greatly reduced number of stitches shows histological results of equivalent quality. At the early stages, the fibrin glue doesn't exceed in volume the usual perianastomotic hematoma. It is completely resorbed within two weeks. Later the scar is thinner than after classical suture, although no ruptures or aneurysms were observed. This method shortens the surgical procedure, with presumed benefit for the drained territories. It diminishes the lesions caused by the stitches. Moreover it allows an easy application of an arterial patch on the sectioned vessel: a comparative series with sutured patches shows on the contrary poor results. Although aggresive for the tissues, a minimal number of stitches remains necessary: it is actually the only available means of correctly positioning the anastomosis area.

The authors report a case of complex traumatic carotid-jugular fistula, and insist on the interest of strict identification of vascular injuries and their haemodynamic consequences, by angiographic study from upper thoracic aorta. Further, the post-operative examination permist verification of the vascular reconstitution.

Epistaxis due to rupture of the carotid, usually occurs as a result of cranial or closed cranio-facial traumatism. Heamorrhage is secondary to the formation of post-traumatic arterial aneurysms or arterio-venous fistulas. Frequently, the lesion is along the intra-cavernous pathway of the internal carotid. Rupture of a spontaneous arterial aneurysm in the sphenoidal sinus is, however, extremely rare. Carotid arteriography is the main method of investigation, and this method alone is capable of detecting the carotid lesion. In addition to obvious cases, it should be requested in cases of severe, copious and recurrent epistaxis when interrogation of the patient reveals the merest hint of trauma, often a long time previously. Immediate treatment consists of anterior bilateral and naso-pharyngeal tampnage. This allows enough time for arteriography to be carried out under the most favourable conditions and also testing for carotid substitution. In order to ensure permanent thrombosis of the aneurysmal pocket or the arteriovenous fistula, most methods resolve themselves into occlusion of the carotid axis. Cervical ligature of the carotid on its own, and isolated trapping have given way to techniques employing either a combination of trapping and embolization, or the placing of a balloon probe without trapping. At present, Serbinenko is advocating using balloons released when arteriography is carried out, obliterating the fistula and left in position permanently. Finally, there is the method by which the sphenoidal sinus is approached para-lateronasally after ethmoidectomy: this is an effective method which is much less incursive than the endo-cranial approach.

Bilateral stenosis of the internal carotid arteries in their extracranial pathway was observed in patient following a road accident. Arteriography was repeated on three occasions, and demonstrated regression of the lesions with complete recovery and lack of sequelae without the need for surgical intervention.

The authors report a case of a bullet wound of the distal region of the left main carotid artery treated successfully by means of angioplasty. They emphasize the rare nature of such lesions in civilian life and discuss the problems related to their diagnosis and therapy.

The authors present 39 carotid lesions from various and sometimes unusual origins: ski accident, cervical irradiation. The lesions have a preferential topography according to etiology: internal carotid for blunt trauma and arteriographic lesions, common carotid for penetrating injuries, common and bifurcation for X-ray lesions. Arteriography and surgical exploration confirm this notion. Macroscopic lesions don't always accord to the classical aspect: thus, only one intimal lesion has been found in blunt trauma. Symptomatology is orientated by etiology: neurological symptoms in blunt trauma and X-ray lesions, vascular symptoms in penetrating injuries. The diagnosis has sometimes been made at a distance from the initial accident and in unusual circumstances, mainly in blunt trauma. The treatment has been a surgical one except for usual countra-indications. The results are favourable on young subjects and above all for particular lesions such as penetrating injuries and X-ray lesions. Lastly, the authors insist on the post-operative evolutivity which is often misunderstood, and on the interest of an angiographic control.

Aneurysms of the cervical internal carotid artery are not rare lesions although they often remain symptomless. The authors describe the case of an eighteen-year-old boy presenting bilateral cervical internal carotid artery aneurysms of probable traumatic origin and treated conservatively. Etiology, pathogenesis, difficulties in diagnosis and choice of treatment are discussed.