Introduction

There have been many case reports of arteriovenous (AV) fistulae occurring after trauma, but most usually present with the classic symptoms of a bruit or pulsatile mass with neurologic deficits. There has only been one case of a vertebral AV fistula reported in a pediatric patient. In this paper, we present a six year-old female with acute onset of neck swelling and no classic symptoms.

Rapidly Expanding Neck Mass in a Six-year-old Female: Case of a Traumatic AV Fistula

Allan Damian, MD*; Andres Boadella, MD**; Jorge Sainz, MD***, Victor Olivas, MD*****PGY-2, Department of Pediatrics, Texas Tech University Health Sciences Center PLF-SOM**PGY-3, Department of Pediatrics, Texas Tech University Health Sciences Center PLF-SOM

***Director of Pediatric Intensive Care Unit, El Paso Children’s Hospital****Clinical Instructor, Department of Surgery, Texas Tech University Health Sciences Center PLF-SOM

Proposed Mechanism

• Most cases of traumatic AV fistula have been reported during wartime as majority are complications from penetrating trauma (i.e., bullet wounds and shrapnel).

• They can sometimes be complicated by pseudoaneurysms as in our case.

•  AV fistula occurred after the sharp object ruptured the vertebral artery.

• The object then ricocheted upon hitting the vertebra, and finally resting on the muscular sheath.

• Penetration created a communicating tract between the artery and vein. The tamponade effect of the surrounding musculature was not enough to prevent an expanding hematoma.

• Damaged arterial wall created a weakened area leading to an aneurysm.

• The foreign body was identified at the level of C6 on the CT scan. The area of the AV fistula corresponds to the V2 segment of the vertebral artery.

Case Summary

• Patient is a 6 y/o female who presented to a local ED with right-sided neck swelling.

• Few hours prior, she was hit by a piece of metal on the right side of the neck while playing with a mallet, pounding it on a rusty anvil.

• Within half an hour, she developed progressive right-sided neck swelling that started spreading to the anterior aspect of her neck. She complained of dysphagia but no difficulty of breathing or any other symptoms.

• At the ED in New Mexico trachea was noted as deviated to the left side. Neck radiograph done at that time showed a small radioopaque material near C6, and soft tissue swelling. With the progression of symptoms, patient was intubated prophylactically and transfer was arranged to our institution for surgical management. She had just undergone contrast CT just prior to being transferred. (refer to Figure 1)

Lessons for the Clinician

In traumatic, especially penetrating injuries to the neck with an expanding hematoma, there should be a high index of suspicion for vascular injuries.

In such cases, alternative means of imaging such as angiography or duplex scan should be employed to rule out a traumatic disruption prior to surgical exploration.

Lack of clinical symptoms does not necessarily rule out injury. Therefore, a multidisciplinary approach involving both clinical and radiological evidence is warranted.

In this patient, surgical exploration was employed to remove the potential infectious risk of this particular projectile. Angiographic embolization greatly facilitated surgery.

Hospital Course

1. Nagpal K, Ahmed K, Cuschieri, RJ. Diagnosis and management of acute traumatic arteriovenous fistula. Int J Angiol 2008; 17(4):214-216.

2. Linde LM, Fonkalsrud EW, Wilson GH, Batzdorf U. Traumatic vertebral arteriovenous fistula in a child. JAMA 1970; 213(9):1465-1468.

3. Frandsen PH. Arteriovenous fistula following blunt trauma. BMJ 1958; 895-896.

4. Leape LL, Palacios E. Acute traumatic vertebral arteriovenous fistula. Ann Surg 1971; 174(6): 908-910.

5. Berguer R, Feldman AJ, Wilner HI, Lazo A. Arteriovenous vertebral fistulae cure by combination of operation and detachable intravascular balloon. Ann Surg 1982; 196(1): 65-68.

6. Thomson A, Miles A. “Traumatic aneurysm” in Manual of Surgery 6th ed, accessed: http://www.manual-of-surgery.com/content/0078-Traumatic-Aneurysm.html (7-29-2012).

7. Boot BP, Macdonald JHM, Parker GD, Jankelowitz S. Teaching neuroimages: traumatic vertebral arteriovenous fistula. Neurology 2011; 76(7 ):e29-e30.

8. Herrera DA, Vargas SA, Dublin AB. Endovascular treatment of traumatic injuries of the vertebral artery. Am J Neuroradiol. 2008; 29: 1585-1589.

2013 Texas Pediatric Society Electronic Poster Contest

References

• Neck X-rays were obtained. (see Figure 2) CT images from New Mexico were reviewed, and there was concern for exsanguination upon planned foreign body extraction.

• The metal was near a vascular area of the neck - anterior to the carotid sheath, at the level of C6. Angiography was then pursued.

• Emergent vertebral artery angiography which showed a traumatic aneurysm and a high-flow AV fistula at the V1 segment, just prior to V2.

• Patient then underwent embolization of the right vertebral artery using a total of nine (9) microventin coils. (see Figure 3) Flow was checked to the left side of the brain through the left vertebral artery.

• Foreign body extraction was performed right after the angiography and blood loss was minimal. (see Figure 4)

• She spent a total of three days at the PICU and was discharged in stable condition.

After angiography, patient underwent foreign body extraction with minimal blood loss.

This patient underwent coil embolization of the malformations, with excellent outcome. Ligation without the former would have been difficult with more blood loss.

LEFT: Figure 1. Original CT scan from NM showing FB

ABOVE: Figure 2. Neck X rays taken at UMC showing location of FB

Figure 5. CT showing the 1) vetebral artery (VA – orange) punctured by the metal fragment; 2) extravasated blood (E – green); 3) venous complex (J – blue); and 4) the foreign body (FB – red).

< Figure 3 (Left). A total of 9 microventin coils inserted to embolize the right vertebral artery

^ Figure 4 (Above). Foreign body extraction and evacuation of hematoma followed angiography