The references below illustrate some rare causes of palpable carotid artery thrills.
Thrills that are palpated at various locations on the chest wall have other, more commonly recognized causes.
Aortic stenosis, pulmonic stenosis and ventricular septal defect may give rise to a palpable thrill at the upper sternal area.
The thrill of aortic stenosis may be more readily palpable over the carotid arteries.
The thrill of a patent ductus arteriosus may be palpable in systole and in diastole.
Increased blood flow in the pulmonary artery due to an atrial septal defect (even without associated pulmonic stenosis) may also give rise to a faint thrill at the upper left sternal border.
Mitral insufficiency may give rise to a palpable apical systolic thrill.
Mitral stenosis may give rise to a palpable apical diastolic thrill.
Sanchez ME, Garcia-Palmieri MR, Quintana CS, Kareh J.
Heart failure in rupture of a sinus of valsalva aneurysm.
Am J Med Sci. 2006 Feb;331(2):100-2.
Department of Medicine, University of Puerto Rico, School of Medicine, and Cardiovascular Center of Puerto Rico and the Caribbean.
We report a 22-year-old man who developed shortness of breath after lifting weights and then developed acute heart failure due to rupture of an aneurysm of the right sinus of Valsalva into the right ventricle. The patient developed dyspnea, and clinical findings included tachycardia, wide pulse pressure, bounding carotid and peripheral pulses, pulmonary crackles, and prominent continuous precordial murmur with thrill. Transesophageal echocardiogram with Doppler examination confirmed the diagnosis. The patient underwent surgery with cardioplegia directly infused into the coronary arteries with excision of redundant tissue and closure of the defect with a Dacron patch. He has been asymptomatic since surgery. This condition must to be included in the differential diagnosis for young patients with heart failure.
Hazinedaroglu S, Genc V, Aksoy AY, Koksoy C, Tuzuner A, Atahan E.
A late onset carotido-jugular fistula following shotgun injury.
Vasa. 2004 Feb;33(1):46-8.
Ankara University Medical School, Department of Surgery, Ankara, Turkey. firstname.lastname@example.org
The incidence of arteriovenous fistulae (AVF) is quite rare in the head and neck region comprising less than 4% of all the traumatic AVF encountered elsewhere in the body. A 42-year-old man presented with a palpable thrill in the cervical region and headache. He had a shotgun injury 10 years ago and had no problem until the previous three months. Diagnosis of a high output traumatic AVF between right common carotid artery and internal jugular vein was made arteriographically. Presence of a neighbouring traumatic aneurysm on the common carotid artery and 9 mm diameter of the fistula tractus suggested open surgery. At the operation ligation of the tractus and aneurysmorraphy was performed and the patient was discharged in the third postoperative day. He has still no problem. This case documented that a shotgun injury even 10 years later may result with an AVF.
Thomas JA, Ware TM, Counselman FL.
Internal carotid artery pseudoaneurysm masquerading as a peritonsillar abscess.
J Emerg Med. 2002 Apr;22(3):257-61.
Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia 23507, USA.
Blunt carotid arterial injuries are uncommon. Motor vehicle crashes are the most frequent cause, but this type of vascular injury can be secondary to any direct blow to the neck, intraoral trauma, or strangulation. Types of vascular injuries include dissection, pseudoaneurysm, thrombosis, rupture, and arteriovenous fistula formation. Patients with pseudoaneurysm of the internal carotid artery will usually present with neurologic complaints, ranging from the minor to complete stroke. On physical examination, neck hematoma, bruits, pulsatile neck mass , or a palpable thrill may be found. However, in 50% of cases, no external signs of neck trauma are observed. Onset of symptoms may occur within a few hours to several months after the initial injury. Angiography is considered the gold standard for diagnosis, but carotid Doppler ultrasound recently has been shown to be very sensitive in detecting these types of injuries. Treatment of pseudoaneurysm is often surgical, with endovascular stenting.
Braksiek RJ, Roberts DJ.
Amusement park injuries and deaths.
Ann Emerg Med. 2002 Jan;39(1):65-72.
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. email@example.com
Media coverage of amusement park injuries has increased over the past several years, raising concern that amusement rides may be dangerous. Amusement park fatalities and increases in reported injuries have prompted proposed legislation to regulate the industry. Since 1979, the medical literature has published reports of 4 subdural hematomas, 4 internal carotid artery dissections , 2 vertebral artery dissections, 2 subarachnoid hemorrhages, 1 intraparenchymal hemorrhage, and 1 carotid artery thrombosis with stroke, all related to roller coaster rides. In this article, we review reports of amusement park injuries in the medical literature and Consumer Product Safety Commission data on the overall risk of injury. We also discuss the physics and the physiologic effects of roller coasters that may influence the type and severity of injuries. Although the risk of injury is low, emergency physicians are advised to include participation on thrill rides as part of their history, particularly when evaluating patients presenting with neurologic symptoms.
Zakhariev T, Chervenkov V, Govedarsky V, Chirkov A.
Our experience in the diagnosis and treatment of carotid-jugular fistulae
Khirurgiia (Sofiia). 1999;55(4):16-9. Bulgarian.
Clinic of Vascular Surgery, Government University Hospital "St Catherine," Sofia, Bulgaria.
We present our experience in treatment of patients with carotid-jugular fistulas for a three years period. Three of those patients had congenital fistulas and one had acquired (posttraumatic) fistula. Signs and symptoms include: pulsatile neck mass , systolic murmur, thrill, dilated superficial veins. Diagnosis was confirmed with Duplex ultrasonography and angiography. Patients were treated by open surgery (ligation and resection) and endovascular procedures (conventional and laser embolization). In cases of single A-V communication ligation and resection gives excellent results. In cases of multiple communications recurrence in the same or neighbouring vascular area is more likely and second stage surgery or/and endovascular procedures (embolization) may be needed.
Sekharan J, Dennis JW, Veldenz HC, Miranda F, Frykberg ER.
Continued experience with physical examination alone for evaluation and management of penetrating zone 2 neck injuries: results of 145 cases.
J Vasc Surg. 2000 Sep;32(3):483-9.
Department of Surgery, University of Florida Health Science Center, Jacksonville, FL 32209, USA.
PURPOSE: Our preliminary experience with physical examination alone in the evaluation of penetrating zone 2 neck injuries for vascular trauma was previously reported in 28 patients over a 2-year period (1991-1993). The purpose of the current study was to examine the results of this approach in a much larger group of patients over an 8-year period. METHODS: The medical records for all patients admitted to our level I trauma center (all of them entered into our prospective protocol) between December 1991 and April 1999 with penetrating zone 2 neck trauma were reviewed for their initial presentation and any documented vascular injury. RESULTS: A total of 145 patients made up the study group; in 30 of these patients, the penetrating trajectory also traversed zone 1 or 3. Thirty-one patients (21%) had hard signs of vascular injury (active bleeding, expanding hematoma, bruit/thrill , pulse deficit, central neurologic deficit) and were taken immediately to the operating room; 28 (90%) of these 30 patients had either major arterial or venous injuries requiring operative repair (the false-positive rate for physical examination thus being 10%). Of the 114 patients with no hard signs, 23 underwent arteriography because of proximity of the injury to the vertebral arteries or because the trajectory included another zone. Of these 23 arteriograms, three showed abnormalities, but only one required operative repair. This case had no complications relating to the initial delay. The remaining 91 patients with no hard signs were observed without imaging or surgery for a minimum of 23 hours, and none had any evidence of vascular injury during hospitalization or during the initial 2-week follow-up period (1/114; false-negative rate for physical examination, 0.9%). CONCLUSIONS: This series confirms the earlier report indicating that patients with zone 2 penetrating neck wounds can be safely and accurately evaluated by physical examination alone to confirm or exclude vascular injury. The missed-injury rate is 0.7% (1/145) with this approach, which is comparable to arteriography in accuracy but less costly and noninvasive. Long-term follow-up is needed to confirm this management option.
Dallo L, Pastrana C, Rodriguez G, Medina Mora O, Barragan R, Bialostozky D.
Acquired systemic arteriovenous fistulas. Experience of 33 cases.
Arch Inst Cardiol Mex. 1984 Mar-Apr;54(2):159-66. Spanish.
We analyzed 33 cases of Acquired Systemic Arteriovenous Fistulas (FAVSA) seen in the INC-ICH between 1945 and 1981. The most frequent causes were traumatic (gunshot and knife wounds) and iatrogenic (surgery). The most affected vessels were femoral, carotid, axillary and subclavian. The FAVSA produced a hyperkinetic hemodynamic syndrome of high output that frequently resulted in fistular cardiopathy. Fistular cardiopathy and heart failure became evident from 4 days to 31 years after the initial insult and was related to the magnitude of the arteriovenous shunt. The latter depended on the distensibility of the communicating ring (the development of perifistular fibrosis did not allow dilatation of the fistular opening). Heart failure was a result of the magnitude of the shunt, even when the patient was young with a healthy heart. A detailed traumatic or surgical history was extremely important in the diagnosis. Relevant physical signs included: bounding pulses, a wide pulse pressure, the presence of a continuous murmur and thrill, a positive Nicoladoni-Branham's sign with a decrease in the heart rate and an increase in systemic blood pressure when the FAVSA was compressed. The existence of the condition became suspicious when heart failure appeared otherwise unexplained by an obvious cardiac lesion. Other important signs included the development of distal venous insufficiency and the presence of a palpable pulsatile mass. Fistular cardiopathy was observed in 60% of the cases studied, although the ECG was normal in 33%; 73% had cardiomegaly which improved with correction of the FAVSA. The treatment is necessarily surgical and required the appropriate technique.
Dodson T, Quindlen E, Crowell R, McEnany MT.
Vertebral arteriovenous fistulas following insertion of central monitoring catheters.
Surgery. 1980 Mar;87(3):343-6
Iatrogenic vertebral arteriovenous fistulas were first reported in 1963. Since then, 20 additional cases have been reported--all following angiographic procedures. We report herein the first recognized cases of such fistulas resulting from percutaneous internal jugular and subclavian venous catheterizations performed for routine hemodynamic monitoring. The symptoms of late-occurring cervical bruit and thrill were identical to those described previously, although the ability to obliterate the thrill by pressure on the common carotid artery in one patient was inconsistent with other experience. These two patients were treated by direct ligation of the fistulous communication, after careful preoperative localization by angiography. Both patients have had complete disappearance of the symptoms and signs of the fistulas.
Kuss JJ, Karli A, Fischbach M, Lutz JD, Dietemann JL, Eisenmann B, Kieny R, Levy JM.
Congenital carotid to jugular aneurysm.
Arch Fr Pediatr. 1979 May;36(5):502-7. French.
A congenital carotid--jugular aneurysm was responsible for severe heart failure in a two day old baby. The child recovered after surgery. The signs suggesting an arteriovenous fistula (a continuous murmur and thrill , hyperdynamic circulation) may be absent, as in this case, when the child is in severe cardiac failure. The signs should be sought when the circulation improves.
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