Carotid Artery Injury During Endoscopic Endonasal Skull Base Surgery

Gardner, Paul A.; Tormenti, Matthew J.; Pant, Harshita; Fernández-Miranda, Juan C.; Snyderman, Carl H.; Horowitz, Michael

doi:10.1227/01.neu.0000430821.71267.f2

Cited by 107 publications

(179 citation statements)

References 36 publications

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“…Regardless of cause and a standardized value, decreased ICD should be considered in all cases of TNTS intended for surgical management of acromegaly, as intraoperative carotid injury, though rare, is potentially devastating. 18 Aside from a careful review of preoperative imaging, one additional strategy is to dissect through the sellar face layer-by-layer and refer to intraoperative Doppler ultrasound to precisely map out the course of the carotid arteries relative to the surgical field. Depending on surgeon preference, the intraoperative image guidance may also be helpful in this endeavor.…”

Section: Discussionmentioning

confidence: 99%

Anatomic Variations in Pituitary Endocrinopathies: Implications for the Surgical Corridor

et al. 2016

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Section: Discussionmentioning

confidence: 99%

Anatomic Variations in Pituitary Endocrinopathies: Implications for the Surgical Corridor

et al. 2016

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“…In the transsphenoidal approach for pituitary adenomas, detailed preoperative planning with information regarding the sphenoid sinus, tumoral involvement of adjacent structures (cavernous sinus, suprasellar region, carotid arteries) and intercarotid distance (ICD) is critical. Despite that, there is little literature regarding the ICD at the parassellar region of the intracranial carotid arteries at its cavernous segment and its modifications due to the sellar pathologies, specially non-functioning pituitary adenomas 2,3,4,5,6 .Although vascular injuries have become less frequent over the years, with reports ranging from 0-3.8% 7,8,9,10,11,12,13,14,15,16,17,18,19,20 , it is still considered one of the most important complications in the transsphenoidal approaches due to its potential hazardous effects and difficult management. Taking this into consideration, it is crucial that every surgeon knows exactly the carotid artery position and its relation to the lesion.…”

mentioning

confidence: 99%

“…Although vascular injuries have become less frequent over the years, with reports ranging from 0-3.8% 7,8,9,10,11,12,13,14,15,16,17,18,19,20 , it is still considered one of the most important complications in the transsphenoidal approaches due to its potential hazardous effects and difficult management. Taking this into consideration, it is crucial that every surgeon knows exactly the carotid artery position and its relation to the lesion.…”

mentioning

confidence: 99%

Pituitary macroadenoma: analysis of intercarotid artery distance compared to controls

Nunes¹,

Cabral²,

Mello³

et al. 2016

Arq. Neuro-Psiquiatr.

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Despite all the improvement in transsphenoidal surgery, the anatomical knowledge has been a main issue stressed by most authors 1 . In the transsphenoidal approach for pituitary adenomas, detailed preoperative planning with information regarding the sphenoid sinus, tumoral involvement of adjacent structures (cavernous sinus, suprasellar region, carotid arteries) and intercarotid distance (ICD) is critical. Despite that, there is little literature regarding the ICD at the parassellar region of the intracranial carotid arteries at its cavernous segment and its modifications due to the sellar pathologies, specially non-functioning pituitary adenomas 2,3,4,5,6 .Although vascular injuries have become less frequent over the years, with reports ranging from 0-3.8% 7,8,9,10,11,12,13,14,15,16,17,18,19,20 , it is still considered one of the most important complications in the transsphenoidal approaches due to its potential hazardous effects and difficult management. Taking this into consideration, it is crucial that every surgeon knows exactly the carotid artery position and its relation to the lesion.This study has the aim to measure and analyze ICD in a series of patients with non-functioning pituitary adenomas with no previous treatment and correlate the data with measurements in controls with no endocrinological, sellar or parassellar disease. AbstrACtObjective: To evaluate the intercarotid distance (ICD) of patients with pituitary macroadenoma and compare to heatlhy controls. Method: We retrospectively reviewed contrast-enhanced MRI images from twenty consecutive patients diagnosed with non-functioning pituitary macroadenoma, measured the ICD at two different levels (petrous segment -ICD1 and horizontal cavernous segment -ICD2) and compared to twenty paired controls. Results: There was no statistically significant difference of the mean ICD1 between the groups and subgroups. For the ICD2 there was statistically significant difference between the case and controls. However, there was no significant difference between the patients with smaller adenomas and the controls. In contrast, the patients with giant adenomas showed statistically significantly higher ICD2 than the controls. Conclusion: The ICD at the horizontal segment of the cavernous carotid tends to be wider in patients with giant pituitary adenomas than in healthy individuals or patients with smaller adenomas.Keywords: Pituitary gland; pituitary disease; internal carotid artery; endoscopy; sella turcica. resumo Objetivo: Avaliar a distância intercarotídea (DIC) de pacientes com macroadenoma de hipófise e comparar com controles saudáveis. Método: Foram analisados retrospectivamente imagens de ressonância magnética com contraste de vinte pacientes consecutivos com diagnóstico de macroadenoma hipofisário não-funcionante, medidas as DIC em dois níveis diferentes (segmento petroso -DIC1 e segmento cavernoso horizontal -DIC2) e comparados com vinte controles pareados. Resultados: Não houve diferença estatisticamente significativa da DIC1 média entre os grupos e su...

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“…7 In the absence of prior balloon test occlusion, intraoperative SSEP becomes the surrogate for the physiological impact of arterial injury or occlusion. This is illustrated by the case example, whereby the decision to completely occlude the injured ICA both intraoperatively and postoperatively was made based solely on SSEP data.…”

Section: Ssep and Baepmentioning

confidence: 99%

Intraoperative neurophysiological monitoring during endoscopic endonasal surgery for pediatric skull base tumors

Elangovan¹,

Singh²,

Gardner³

et al. 2016

PED

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OBJECT The aim of this study was to evaluate the value of intraoperative neurophysiological monitoring (IONM) using electromyography (EMG), brainstem auditory evoked potentials (BAEPs), and somatosensory evoked potentials (SSEPs) to predict and/or prevent postoperative neurological deficits in pediatric patients undergoing endoscopic endonasal surgery (EES) for skull base tumors. METHODS All consecutive pediatric patients with skull base tumors who underwent EES with at least 1 modality of IONM (BAEP, SSEP, and/or EMG) at our institution between 1999 and 2013 were retrospectively reviewed. Staged procedures and repeat procedures were identified and analyzed separately. To evaluate the diagnostic accuracy of significant free-run EMG activity, the prevalence of cranial nerve (CN) deficits and the sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 129 patients underwent 159 procedures; 6 patients had a total of 9 CN deficits. The incidences of CN deficits based on the total number of nerves monitored in the groups with and without significant free-run EMG activity were 9% and 1.5%, respectively. The incidences of CN deficits in the groups with 1 staged and more than 1 staged EES were 1.5% and 29%, respectively. The sensitivity, specificity, and negative predictive values (with 95% confidence intervals) of significant EMG to detect CN deficits in repeat procedures were 0.55 (0.22–0.84), 0.86 (0.79–0.9), and 0.97 (0.92–0.99), respectively. Two patients had significant changes in their BAEPs that were reversible with an increase in mean arterial pressure. CONCLUSIONS IONM can be applied effectively and reliably during EES in children. EMG monitoring is specific for detecting CN deficits and can be an effective guide for dissecting these procedures. Triggered EMG should be elicited intraoperatively to check the integrity of the CNs during and after tumor resection. Given the anatomical complexity of pediatric EES and the unique challenges encountered, multimodal IONM can be a valuable adjunct to these procedures.

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Carotid Artery Injury During Endoscopic Endonasal Skull Base Surgery

Abstract: ICA injury during endonasal skull base surgery is an infrequent and manageable complication. Preservation of the vessel remains difficult. Chondroid tumors represent a higher risk and should be resected by surgical teams with significant experience.

Cited by 107 publications

References 36 publications

Anatomic Variations in Pituitary Endocrinopathies: Implications for the Surgical Corridor

Anatomic Variations in Pituitary Endocrinopathies: Implications for the Surgical Corridor

Pituitary macroadenoma: analysis of intercarotid artery distance compared to controls

Intraoperative neurophysiological monitoring during endoscopic endonasal surgery for pediatric skull base tumors

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