What is the treatment approach for an aneurysm in the cervical region?

Treatment Approach for Cervical Region Aneurysms

For cervical (neck) region aneurysms involving the extracranial carotid arteries, surgical treatment is required in most cases to prevent disastrous complications, as conservative management has resulted in mortality rates approaching 71%. 1

Understanding Cervical Aneurysm Location and Etiology

Cervical aneurysms refer to aneurysms of the extracranial carotid arteries in the neck region, which are rare and account for only 0.4-1% of all arterial aneurysms. 1 These differ fundamentally from intracranial (brain) aneurysms in both natural history and treatment approach.

Key anatomical sites:

• Most commonly occur at the common carotid artery bifurcation and proximal internal carotid artery (ICA) 1
• Middle and distal portions of the ICA are next most common 1
• Bifurcation aneurysms are typically fusiform, while middle/distal ICA aneurysms are usually saccular 1

Primary causes:

• Atherosclerosis accounts for 46-70% of cases 1
• Trauma (penetrating, blunt cervical trauma, neck hyperextension) 1
• Fibromuscular dysplasia, infection, congenital defects, and radiation arteritis 1

Clinical Presentation and Risk Assessment

Typical presentation:

• Parapharyngeal pulsatile neck mass 1
• May be partially or completely thrombosed 1

Major complications to prevent:

• Thromboembolism (more common than rupture in cervical aneurysms, unlike intracranial aneurysms) 2
• Compression of neurovascular structures 1
• Rupture (less common but catastrophic) 1
• Ischemic stroke events 1

Diagnostic Imaging Algorithm

Initial evaluation:

• Duplex ultrasound to confirm presence and assess size, thrombosis, and hemodynamic impact 3
• CTA with IV contrast for detailed anatomical definition (>90% sensitivity and specificity) 3

Definitive imaging:

• Digital subtraction angiography remains the gold standard for surgical planning 3
• MRA can be used as a noninvasive alternative (95% sensitivity, 89% specificity) but is more commonly used for intracranial aneurysms 3

Treatment Decision Algorithm

Indications for Surgical Intervention (Most Cases)

Operate on:

• All symptomatic cervical aneurysms (pulsatile mass, neurologic symptoms, embolic events) 1
• Large or rapidly expanding aneurysms 3
• Aneurysms with evidence of thromboembolism 1
• Progressive expansion despite conservative management 1
• Persistent neurologic symptoms on anticoagulation 1

Surgical approach:

• Open surgical repair is the definitive treatment 3
• Options include aneurysm resection with primary repair, interposition grafting, or bypass 1
• Endovascular stent grafts are reserved for patients with surgical contraindications, though this carries infection risk 3

Rare Exceptions for Conservative Management

Consider observation only in:

• Young patients with nonpenetrating traumatic aneurysms 1
• Spontaneously dissecting aneurysms in young patients 1
• Post-traumatic pseudoaneurysms that may spontaneously thrombose (documented in case reports within 10 days) 4

Conservative management requires:

• Anticoagulation therapy 1
• Close imaging surveillance for expansion 1
• Immediate conversion to surgery if anticoagulation fails, neurologic symptoms persist, or progressive expansion occurs 1

Critical Pitfalls to Avoid

Do not confuse cervical (extracranial carotid) aneurysms with intracranial aneurysms:

• Intracranial aneurysms <5 mm can often be observed conservatively 3
• Cervical aneurysms require surgical treatment regardless of size due to high mortality with conservative management (71%) 1

Do not delay surgical referral:

• Conservative management of extracranial carotid aneurysms has unacceptably high mortality 1
• Thromboembolism and rupture risks mandate intervention 1, 2

Do not use CTA neck for intracranial aneurysm surveillance:

• There is no literature supporting CTA neck for cerebral aneurysm surveillance 3
• This distinction is critical—cervical aneurysms are extracranial pathology requiring different imaging and treatment 1

Monitoring and Follow-up

Post-surgical surveillance:

• Duplex ultrasound to assess graft patency and detect new aneurysm formation 3
• Imaging of arterial inflow and venous outflow to assess for stenosis 3

If conservative management is attempted (rare):

• Serial imaging to detect expansion 1
• Maintain anticoagulation 1
• Low threshold for surgical conversion 1