Interventional Neuroradiology 17: 386-390, 2011www.centauro.it

Subcutaneous Hematoma Associatedwith Manual Cervical Massage during
Carotid Artery Stenting
A Case Report
A. tSuRuMI4, Y. tSuRuMI2, M. NEgORO3, K. YOKOYAMA4, M. OHEdA4, N. SuSAKI4,
S. tSugANE4, t. tAKAHASHI4, S. MIYACHI1
1 Nagoya University Graduate School of Medicine; Nagoya, Japan

2 Department of Neurosurgery, Japanese Red Cross Nagoya Daiichi Hospital; Nagoya, Japan
3 Department of Neurosurgery, Fujita Health University; Toyoake, Japan

4 Department of Neurosurgery, National Hospital Organization Nagoya Medical Center; Nagoya, Japan

Key words: carotid artery stenting, cervical hemorrhage, manual compression

Summary
We describe a patient with subcutaneous hematoma associated with manual cervical massage during carotid artery stenting.
A 73-year-old man with left cervical carotid
artery stenosis presented with left amaurosis fugax. We performed carotid artery stenting using
distal embolic protection with balloon occlusion. Dual antiplatelet therapy was maintainedin the periprocedural period and an anticoagulant agent was administered during the procedure. Because the aspiration catheter became
entrapped by the stent, it did not reach the distalside of the stenotic lesion, and manual compression of the cervical region was therefore performed. Immediately afterwards, a subcutaneous
hemorrhage occurred in the cervical region.
There was no postoperative dyspnea due to enlargement of the hematoma, which was absorbed
spontaneously.
Cervical subcutaneous hematoma can occur
in the cervical region due to cervical massage inpatients who are receiving adjuvant antiplatelet
therapy and anticoagulation therapy.
Introduction
Cervical subcutaneous hematoma is a rarecomplication of carotid artery stenting (CAS) 1.
Because dual antiplatelet and anticoagulant
386

therapy are administered during the periprocedural period of CAS, there is a tendency forhematomas to enlarge dramatically should hemorrhage occur. Reported causes of cervicalhematoma include arterial perforation by theguide wire during the procedure and vessel
rupture due to over-inflation of the percutaneous transluminal angioplasty (PtA) balloon 2,3.
to the best of our knowledge, the literature
contains no reports of manual compression of
the cervical region 4 causing the formation of a
cervical subcutaneous hematoma, as the authors experienced. the authors report thepresent case because cervical hematoma is acomplication that can have a detrimental effecton prognosis due to compression of the trachea, causing dyspnea.
Case Report
History
this 73-year-old man presented with leftamaurosis fugax. He was examined in the department of Neurology, where left cervical carotid artery stenosis was identified by magnetic
resonance angiography (MRA) and carotid ultrasonography, and he was referred to the department of Neurosurgery in May 2009. the patient was started on oral clopidogrel (75 mg oncedaily) and aspirin (100 mg once daily), which wasA. Tsurumi

Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting↑ Figure 2 the left cervical area immediately after the pro-cedure. Immediately after manual compression of the neck,
the patient complained of pain in the left cervical area, anda hematoma was observed.

← Figure 1 Left common carotid artery angiography (lat-eral view) before stenting showing a 70% stenosis at theorigin of the left internal carotid artery.

maintained during the perioperative period. Residual platelet reactivity measured by the verifyNow Assay (Accumetrics Inc., San diego, CA,uSA) was 481 Aspirin Reaction units for aspirin and 109 P2Y12 Reaction units for clopidogrel, respectively; these results indicated that both
antiplatelet agents were at therapeutic levels.
Examination
On admission, the patient had no neurological deficit. Brain magnetic resonance imaging
showed no cerebral infarction. Cervical MRA
demonstrated severe stenosis of the left cervical carotid artery. Carotid ultrasonography also
revealed severe stenosis of the left cervical carotid artery, with hypoechoic plaque and calcification. Left common carotid angiography indicated 70% stenosis of the left cervical carotid
artery according to North American Symptomatic Carotid Endarterectomy trial 5 (NASCEt) Criteria (figure 1). Right common carotid angiography demonstrated a 70% stenosis of the petrous portion of the right internal
carotid artery. Aortography indicated that theleft common carotid artery originated from thebrachiocephalic artery.

Carotid Artery Stenting Procedure and Post
Treatment Course
Local anesthesia was administered to the patient. We then intravenously administered 4000
units of heparin to achieve an activated coagulation time of 258 s. A 90-cm 6-french guidesheath (Shuttle-SL; Cook Medical, Bloomington, IN, uSA) was inserted into the right radial
artery and advanced until its tip reached the leftcommon carotid artery by means of a coaxialsystem. A 125-cm 4-french catheter (Ceruleang; Medikit, tokyo, Japan) and an angled
0.035-inch hydrophilic guidewire (Radifocus
guide wire M; terumo, tokyo, Japan) were inserted into the 6-french guide sheath by meansof the coaxial system, enabling easy insertion ofthe tip of the sheath as far as the left common
carotid artery. there was no arterial penetrationby the wire or catheter. using a roadmap, a PercuSurge guardWire (Medtronic, Minneapolis,MN, uSA) was advanced into the distal cervicalinternal carotid artery. After distal embolic protection with balloon occlusion, balloon angioplasty with a 4×40-mm Sterling balloon (Boston Scientific, Natick, MA, uSA) (inflated to 6
atm/30 s) resulted in suboptimal recanalization,387

Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting

therefore a 10×40-mm Precise carotid stent(Cordis, Miami Lakes, fL, uSA) was advanced
over the wire and deployed across the stenotic
lesion in the internal and common carotid arteries. the residual stenosis was treated by temporary inflation of a 5×20-mm Sterling balloon (inflated to 6 atm/15 s) in the waist (residual stenosis) of the stented lesion. When an aspiration
catheter (Eliminate; terumo) was then advanced
to the vicinity of the PercuSurge guardWire
balloon, its tip caught on the strut of the Precisestent and could not be advanced further. Measures such as swallowing saliva, turning the headto the right and left, and inserting the 0.035-in
guide wire into the aspiration lumen of the
Eliminate catheter were ineffective, and the
Eliminate catheter could only be advanced to
the vicinity of the PercuSurge guardWire balloon after manual compression of the left cervical region to change the direction of the internal
carotid artery.
dispersed plague and blood were aspirated
from the eliminate catheter, but immediately after manual compression of the neck the patientcomplained of pain, and a left cervical hematoma was observed (figure 2). the patient did notexperience dyspnea. Angiography of the leftcommon carotid artery was immediately performed, but this showed no extravasation ofcontrast medium. the stenosis was adequately
dilated (figure 3). the sheath was removed immediately at completion of the procedure, andhemostasis was obtained using a radial arterycompression device. Activated coagulation timeafter completion was 230 s. Cervical computed
tomography was performed immediately, andshowed displacement of the trachea to the rightby a large left cervical subcutaneous hematoma(figure 4). the patient was transferred to the
Neurological Care unit and remained neurologically intact. No new anticoagulation therapy
was added after surgery, although the previous
antiplatelet agents were continued postoperatively. the patient’s subcutaneous hematoma
did not enlarge, and he was discharged in stablecondition five days after the procedure. three
weeks after the procedure, the cervical hematoma had improved (figure 5).
Discussion
formation of cervical hematoma has beenreported as a complication of carotid arterystenting 1. Reported causes of hematoma in388

A. Tsurumi

clude arterial perforation by the guide wireand rupture of the carotid artery due to overinflation of the PtA balloon 2,3. In all such reports, the cause has been arterial hemorrhage
resulting in marked enlargement of the hematoma, compressing the trachea and requiring endotracheal intubation. Arterial hemorrhage in the cervical region is a life-threatening complication. Once the arterial perforation
occurs and the extravasation of the contrast
medium can be visualized, the patency of theairway must be immediately confirmed. Selective embolization of the ruptured artery is effective for hemostasis. A covered stent can beused for a laceration of the carotid artery. In
patients who are given heparin, protamine sulfate can be administered to reverse heparin
anticoagulation.
In the case we describe, the subcutaneous hematoma formed because of manual compression of the neck and cervical massage, a different mechanism of formation from those hitherto reported. Conceivable causes of the hemorrhage were that the tip of the aspiration catheter lacerated the carotid artery or that carotid
massage to the arterial wall, damaged by a wire
during the access to the lesion before stenting,induced the hemorrhage in the cervical region.
Angiography was performed immediately after
the appearance of the subcutaneous hematoma, but it showed no extravasation of contrast
medium. the cause of the subcutaneous hematoma in this patient was therefore regarded
as hemorrhage due to rupture of small subcutaneous vessels as a result of cervical massage.
Hence, protamine sulfate was not used as aheparin antagonist, and the dual antiplatelet
therapy was continued postoperatively so asnot to increase the risk of in-stent thrombosis
in the acute phase of stenting. the patient’s
postoperative course, with little enlargement of
the hematoma and no compression or obstruction of the trachea, meaning that tracheal intubation was not required, supported the hypothesis of hematoma formation not related to arterial perforation or large artery laceration.
In the present case, manual compression of
the neck was necessary because the aspiration
catheter became caught on the stent strut. Incases such as this, appropriate use of an embolic protection device might prevent the occurrence of similar complications. Both proximalprotection methods, involving obstruction of
the common carotid and external carotid arteries using a balloon 6, and distal protection

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Interventional Neuroradiology 17: 386-390, 2011

Figure 3 Left common carotid artery angiography. A) AP view, B) lateral view after stenting showing adequate dilatation of
the stenotic lesion. No extravasation of the contrast medium is seen.

Figure 4 Non-contrast computed tomography, showing alarge subcutaneous hematoma of the left cervical region andtracheal displacement to the right.

Figure 5 Left cervical region 3 weeks postoperatively. thecervical hematoma had improved.

methods using a filter protection device 7 could
be used. the proximal protection method has
the disadvantage of requiring a 10-frenchsheath, making hemostasis difficult at the femoral artery, the sheath puncture site. If a filter
protection device is used, this has the disadvantage that the capture catheter used to recover
the filter often becomes caught on the stentstrut. Whichever method is used, the use ofplaque imaging to analyze plaque characteristics is important for the selection of a safe
method of embolic protection 8-11.

Conclusion
We described a case of cervical subcutaneous
hematoma formation occurring immediately
after cervical massage during carotid arterystenting for cervical carotid artery stenosis. thecause of this subcutaneous hematoma was regarded as massage-induced rupture of smallvessels. Cervical subcutaneous hematoma may
occur as a result of cervical massage in patients
undergoing adjuvant antiplatelet and anticoagulant therapy.

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Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting

A. Tsurumi

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Arihito tsurumi, Md, Phd
department of Neurosurgery,
National Hospital Organization Nagoya Medical Center
tel.: +81-52-951-1111
fax: +81-52-951-0664
E-mail: arihito@tsurumi.pro