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Cite this article: Pearlman RC, Steinberg B (2016) Dense Lymphatic Tissue Causing Compression of the Internal Carotid Artery. J Neurol Disord Stroke 4(2): 1115. 1/2

*Corresponding authorRonald C. Pearlman, Howard University, Department of Communication Sciences and Disorders, Howard University, Washington, D.C. USA, Tel: 240-620-1305; Fax: 240-294-6320; Email:

Submitted: 02 August 2016

Accepted: 31 August 2016

Published: 02 September 2016

Copyright© 2016 Pearlman et al.

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Keywords•Carotid•Endarterectomy•Lymphatic tissue•Stenosis•HIV

Case Report

Dense Lymphatic Tissue Causing Compression of the Internal Carotid ArteryRonald C. Pearlman1*, and Bryan Steinberg2

1Department of Communication Sciences and Disorders, Howard University, USA2Depaartment of Cardiac Surgery, Capital Cardiovascular and Thoracic Surgery Associates. USA

Abstract

A 59-year-old HIV positive female presented with cardiac symptomatology. Cardiology workup included a cardiac catheterization during which a carotid angiogram was performed demonstrating a 90% stenosis of the right carotid artery. The stenosis was the result of lymphoid hyperplasia with pseudo - obstruction of the right carotid artery. Patients who have acquired human immunodeficiency virus (HIV) may have enlarged neck lymph tissue impinging on other anatomical structures causing displacement or stenosis, including the carotid artery.

INTRODUCTIONStenosis of the carotid artery can be caused by several

situations. By far the most common cause of occlusion disease is arterial ulcerative or atherosclerotic plaque. However, other neck structures have also been implicated in impinging on the carotid wall causing a narrowing of the blood vessel.

Mandelbaummomit et al., [1] found blunt neck injury resulted in blood - engorged lymph nodes against the internal carotid artery causing constriction of the lumen. Pearlmanomit et al., [2] found the hyoid bone pressing against the internal carotid artery causing significant stenosis. Boldrey et al., [3] reported on the impingement of the carotid by the lateral process of the atlas. Except for cases of blunt neck injury causing enlargement of lymph nodes due to blood-engorgement, a lymph mass hyperplasia causing carotid stenosis has not been reported in the literature.

CASE REPORTThe patient is a 59-year-old female with a history of

smoking, asthma, breathing difficulty, cardiomyopathy, congestive heart failure, chronic obstructive pulmonary disease, dilated cardiomyopathy, hypertension, gingivitis, and human immunodeficiency virus (HIV). The patient initially presented with a complaint of headache, dizziness and possible syncope. Cardiology workup included a cardiac catheterization during which a carotid angiogram was performed demonstrating a 90% stenosis of the right carotid artery. A right carotid endarterectomy was scheduled to increase the size of the blood vessel lumen.

A large mass of lymphatic node tissue measuring approxi-mately 5X4 cm was found during neck dissection (Figure 1) ex-

trinsically compressing the carotid artery. The vessel appeared completely normal and without evidence of plaques by palpation or visual inspection. Duplex sonography was performed intrap-retatively, which confirmed the resolution of the previously seen stenosis and complete patency of the right internal carotid artery (Figure 2). Surgery was terminated without an endarterectomy. The mass was sent to pathology confirming it was lymphatic tis-sue. No other significantly large lymphatic tissue was seen during dissection. Due to a lack of evidence of internal artery stenosis due to plaque the procedure was terminated.

Electroencephalography was used during the procedure for selective shunting as well as brain monitoring during the procedure. Neuromonitoring was unchanged during the procedure when taking anesthesia dosage and blood pressure changes into account. The patient was taken to post anesthesia care awake and in stable condition. The patient was able to

Figure 1 Tissue impinging on the internal carotid artery latter identified by a pathologist as lymphatic tissue.

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respond to commands and move all limbs in the recovery room. Postoperatively the patient had a formal arterial duplex scan of the right carotid artery that demonstrated resolution of the previously observed stenosis.

The pathologist’s final diagnosis was “Cervical lymph node. Flow cytometric immunophenotyping: Heterogeneous B, T and NK cells without aberrant antigen expression or monoclonal B-cell. In summary, there is no definitive immunophenotypic evidence of lymphomal/leukemia”.

DISCUSSIONBarzan et al., [4] found enlargement of neck lymph nodules

in HIV patients and recommended a head and neck evaluation in every HIV infected patient. The patient in this report was infected with the human immunodeficiency virus. The resulting lymphadenopathy compressed the adjacent carotid artery and caused a significant stenosis, > 90%. This finding is unusual in that it is not secondary to blunt trauma to the neck as in the case

Pearlman RC, Steinberg B (2016) Dense Lymphatic Tissue Causing Compression of the Internal Carotid Artery. J Neurol Disord Stroke 4(2): 1115.

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Figure 2 Intraoperative ultrasound showing patency of the carotid artery after removal of lymphatic mass.

report by Mandelbaum and Kalsbeck [1]. While kinking of the carotid artery is fairly common [5] it is rarely due to impinging tissue or structures, except in the case of the hyoid bone as reported by Pearlman and Naficy [2].

CONCLUSIONHIV positive patients are at risk for having false positive

findings on medical imaging studies. Patients who have the human immunodeficiency virus may have enlarged neck lymph tissue impinging on other anatomical structures causing displacement or stenosis, including the carotid artery. This case demonstrates the importance of soft tissue evaluation of cervical lymphadenopathy by either computerized tomography or magnetic resonance imaging in order to verify that implied intrinsic vascular stenosis is in fact due to native vessel diseases and not a false positive finding secondary to extrinsic compression. HIV patients who are asymptomatic for carotid stenosis, but in whom imaging shows lymphatic tissues impinging on the carotid artery should be followed for the advent of symptomatology and considered for surgery if symptoms do arise.

REFERENCES1. Mandelbaum I, Kalsbeck JE, Extrinsic compression of internal carotid

artery. Ann Surg. 1970; 171: 434-437.

2. Pearlman RC, Naficy, MA, Koby MB, Nyanzu M. Carotid artery compression by the hyoid bone. J Vasc Endovascular Surg. 2012; 46: 686-687.

3. Boldrey E, Maass L, Miller E, The role of atlantoid compression in the etiology of internal carotid thrombosis. J Neurosurg. 1956; 13: 127-139.

4. Barzan L, Tavio M, Tirelli U, Comoretto R. Head and neck manifestations during HIV infection. J Laryngol Otol. 1993; 107: 133-136.

5. Quattelbaum JK Jr, Wade JS, Whiddon CM. Stroke associated with elongation and kinking of the carotid artery: long-term follow-up. Ann Surg. 1973; 177: 572-579.