A case of severe carotid blowout syndrome successfully treated with endovascular parent artery occlusion: Additional N-butyl cyanoacrylate embolization under flow control after incomplete coil embolization

Background: Carotid blowout syndrome (CBS) is a potentially fatal complication associated with surgery and irradiation. Carotid artery rupture can cause life-threatening hemorrhage. We report a case of massive hemoptysis due to the rupture of an infected pseudoaneurysm following cervical irradiation for Hodgkin’s lymphoma, which was successfully treated with embolization using coils and N-butyl cyanoacrylate (NBCA). Case Description: A 50-year-old man who had undergone surgery and chemoradiotherapy for Hodgkin’s lymphoma of the left neck 35 years earlier developed massive hemoptysis with transient cardiopulmonary arrest during hospitalization for a deep neck abscess. Cerebral angiography immediately after resuscitation revealed a pseudoaneurysm originating from the left common carotid artery (CCA) extending into the internal carotid artery; however, there was no evidence of contrast extravasation, leading to conservative management. However, the following day, he developed another episode of massive hemoptysis, resulting in shock. Cerebral angiography confirmed contrast extravasation from the CCA, prompting parent artery occlusion (PAO). Although 43 platinum coils were deployed, residual blood flow to the aneurysm persisted. Therefore, 50% NBCA was injected under flow control of the CCA to achieve hemostasis. No new neurological deficits were observed post-treatment. Conclusion: Achieving hemostasis is the highest priority in cases of massive hemorrhage from CCA rupture caused by CBS. After confirming the collateral blood flow from the contralateral intracranial circulation, immediate PAO should be performed. Additional NBCA embolization under parent artery flow control is a valuable option in cases where hemostasis is difficult to achieve using coil embolization alone.