Original Article

Interactive Case Study Female patient with a Bruit in the Neck

X Rothfuss-Kikillus, G Torsello, B Kasprzak

Keywords

aneurysm, aorta, bypass surgery, cardiac, cardio-pulmonary, cardiopulmonary bypass, cardiothoracic, carotid, chest, heart, heart-lung machine, medicine, surgery, thoracic, valve, vascular, vessel

Citation

X Rothfuss-Kikillus, G Torsello, B Kasprzak. Interactive Case Study Female patient with a Bruit in the Neck. The Internet Journal of Thoracic and Cardiovascular Surgery. 1996 Volume 2 Number 1.

Abstract
 

History

In a 36-year old female patient a systolic-diastolic bruit was detected in the right side of the neck during routine check-up.

The patient was asymptomatic.

Clinical examination:

  • Blood pressure: 100/80 mmHg

  • Pulse: 80/min

  • Palpable thrill and systolic-diastolic bruit on the right side of the neck.

  • Clinical examination showed no further abnormalities.

1. What do you suspect?

  • a) Hemangioma?

  • b) Congenital arteriovenous vascular malformation?

  • c) Benign or malignant tumor?

  • d) Thyroid pathology with hypervascularization?

Answer for Question 1

2. Which diagnostic methods would you use?

  • a) Laboratory studies?

  • b) ECG?

  • c) Chest X-Ray?

  • d) CW-Doppler-ultrasound?

  • e) Duplex scan?

  • f) Transcranial Doppler-ultrasound?

  • g) Angiography?

  • h) CT-scan?

  • i) Magnetic resonance imaging?

  • j) MRI-angiography?

Answer for Question 2

Laboratory studies

3. Which laboratory examination can help you to find the right diagnosis?

  • a) Erythrocyte sedimentation rate?

  • b) Blood cell count?

  • c) Coagulation tests?

  • d) Liver function tests?

  • e) Blood urea nitrogen/creatinine?

  • f) Electrolytes?

  • g) Blood glucose?

  • h) Thyroid hormones?

  • i) Electrophoresis?

  • j) C-reactive protein?

Answer for Question 3

Electrocardiography

4. Which findings do you suspect in the case of a patient with arteriovenous fistula?

  • a) Tachycardia?

  • b) Arrhythmia?

  • c) Signs of ventricular hypertrophy?

  • d) Repolarization abnormalities?

Answer for Question 4

Chest X-Ray

5. Why do you think a chest X-ray examination is important?

a) You can detect fistulas within pulmonary parenchyma.
b) There may be other congenital malformations detected by chest X-ray.
c) It is important to exclude a malignant tumor, because until now we do not know the definitive diagnosis.
d) Signs of a congenital heart disease, that is combined with a congenital vascular malformation.
e) Intrathoracic struma.

Answer for Question 5

CW-Doppler-ultrasound and duplex scan

6. Which findings do you suspect in patients with arteriovenous fistula?

  • a) Decreased pulsatility and increased blood flow.

  • b) Increased pulsatility and decreased blood flow.

  • c) There are no helpful findings.

  • d) There are several vessels with different directions and high Doppler frequency as a possible sign of an arteriovenous fistula.

  • e) By using duplex-scanning you can identify vascular and tissue structures.

  • f) By using duplex-scan you can detect the shunting area.

  • g) By using duplex-scan you are able to estimate the size of the shunting volume.

Answer for Question 6

Transcranial Doppler-ultrasound

7. Is this an important diagnostic method in our case?

  • a) Yes.

  • b) No.

Answer for Question 7

Angiography

8. Our patient is asymptomatic and angiography is an invasive diagnostic tool. Would you insist on this method?

  • a) Yes, because angiography enables to estimate the extent of this vascular abnormality, to detect the feeding vessels and to show the shunting area. It is important for follow-up if initially no therapy is necessary.

  • b) No. This method is risky and there are less invasive methods such as computerized tomography that may help you to find the right diagnosis and therapy.

Answer for Question 8

9. Which are the risks of angiography?

  • a) There are no risks.

  • b) Bleeding at the puncture site.

  • c) Infection.

  • d) Rupture of the vessels investigated, dissection of the wall.

  • e) Thromboembolic occlusion of the vessels investigated, occlusion due to spasm.

  • f) Complications by contrast medium.

  • g) Induction of iatrogenic hyperthyroidism after application of contrast medium.

Answer for Question 9

10. Why is angiography helpful for correct diagnosis?

  • a) It indicates the localization and extent of vascular abnormalities.

  • b) Identifying and localizing abnormal, tortuous vessels, feeding vessels and shunting areas.

  • c) To differentiate between benign and malignant vascular tumors, because of their characteristic angiographic pattern.

Answer for Question 10

Computerized tomography and magnetic resonance imaging

11. Why are these diagnostic methods helpful?

  • a) You can see the size and location of a vascular lesion.

  • b) You can get informations on involved structures, relating to neighboured tissue structures.

  • c) In venous vascular malformations these methods are of much greater value to determine size and extent of involvement than arteriography.

Answer for Question 11

12. What do you suppose after all these diagnostic findings?

  • a) Initially supposed diagnosis of an arteriovenous fistula is correct.

Yes.
No.

  • b) Are the performed diagnostic methods sufficient in this case?

Answer for Question 12

Therapy

13. Which therapeutic measures are possible?

  • a) There is no need of intervention because the patient is asymptomatic.

  • b) Surgical treatment: Excision of the vascular malformation.

  • c) Therapeutic embolization of the arteriovenous vessel.

Answer for Question 13

Figure 1
Figure 1: Duplex Scan

Figure 2
Figure 2: Angiography

Figure 3
Figure 3: Intraoperative view with fistula

References

1. B) Congenital arteriovenous vascular malformation
2. All of these diagnostic methods are helpful, but the most important methods are duplex scan (e) and angiography (g)
3. You can examine all of these parameters. Laboratory studies are helpful to detect inflammatory diseases or malignancies. There could be some information about the involvement of other organ systems by vascular malformations. It is important to keep in mind that all diagnostic findings together will lead to the right diagnosis and laboratory studies represent only a small part of the diagnostic possibilities.In our patient we had no pathologic laboratory results.
4. Of course you can find all of these ECG alterations in patients with arteriovenous fistulas. These fistulas represent an abnormal connection between a high-pressure arterial system and a low-pressure venous system. The hemodynamic effect of this shunting is an increased blood flow, heart rate and stroke volume progressing to pulmonary hypertension and cardiac failure in extreme conditions. Therefore all of these non-specific ECG-alterations are possible findings in patients with these vascular malformations.ECG in our case was normal.
5. All of these answers are correct because all of these findings will help you to detect concomitant diseases and to find the right diagnosis. We had no pathologic findings in case of our young patient.
6. A) Decreased pulsatility and increased blood flow.D) There are several vessels with different directions and high Doppler frequency as a possible sign of an arteriovenous fistula.E) By using duplex-scanning you can identify vascular and tissue structures.F) By using duplex-scan you can detect the shunting area.G) By using duplex-scan you are able to estimate the size of the shunting volume.Using duplex-scan we found a fistula between a large vein and an arterial vessel that could represent the thyreocervical trunk. Internal and external carotid artery on both sides of the neck appeared normal.
7. By TCD intracranial vascular abnormalities could be identified. MRI, CT or angiography may give you more information. Both answers are correct.
8. a) Yes, because angiography enables to estimate the extent of this vascular abnormality, to detect the feeding vessels and to show the shunting area. It is important for follow-up if initially no therapy is necessary.
9. b) Bleeding at the puncture site.c) Infection.d) Rupture of the vessels investigated, dissection of the wall.e) Thromboembolic occlusion of the vessels investigated, occlusion due to spasm.f) Complications by contrast medium.g) Induction of iatrogenic hyperthyroidism after application of contrast medium.
10. a) and b) represent correct answers. c) This answer is not correct. There is no characteristic angiographic pattern that allows to differentiate between benign or malignant vascular tumors. Only excision and histological investigation can lead to the right diagnosis.In our case we found an angiodysplasia that consisted of a fistula that connected in multiple loops the right subclavian artery and brachiocephalic vein. In our patient the vertebral artery had its origin from brachiocephalic trunk. Phlebogram of the right upper extremity and vena cava superior was normal but there was an inhomogenous contrasting in a brachiocephalic vein segment due to shunting in the area of the fistula.
11. All answers are correct:a) You can see the size and location of a vascular lesion.b) You can get informations on involved structures, relating to neighboured tissue structures.c) In venous vascular malformations these methods are of much greater value to determine size and extent of involvement than arteriography.
12. a) Yes is correct.b) We cannot give you the answer now.
13. Comment: In our case, surgical treatment was preferred: We found a prominent vessel belonging to the fistula describing numerous coilings and fed by several smaller arteries that were clipped. The fistula represented a connection between thyrocervical trunk and brachiocephalic vein. The excision of the arteriovenous fistula was complete, as demonstrated in a postoperative performed angiography.

Author Information

X. Rothfuss-Kikillus
Department of Vascular Surgery, St. Franziskus-Hospital

G. Torsello
Department of Vascular Surgery, St. Franziskus-Hospital

B. Kasprzak
Department of Vascular Surgery, St. Franziskus-Hospital

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