Internal Carotid Artery Injury in Transsphenoidal Surgery: Tenets for Its Avoidance and Refit—A Clinical Study

Abstract

One of the most serious/potentially fatal complications of transsphenoidal surgery (TSS) is internal carotid artery (ICA) injury. Of 6230 patients who underwent TSS, ICA injury occurred in 8 (0.12%). The etiology, possible treatment options, and avoidance of ICA injury were analyzed. ICA injury occurred at two different stages: (1) during the exposure of the sella floor and dural incision over the sella and cavernous sinus and (2) during the resection of the cavernous sinus extension of the tumor. The angiographic collateral blood supply was categorized as good, sufficient, and nonsufficient to help with the decision making for repairing the injury. ICA occlusion with a balloon was performed at the injury site in two cases, microcoils in two patients, microcoils plus a single barrel extra-intracranial high-flow bypass in one case, stent grafting in one case, and no intervention in two cases. The risk of ICA injury diminishes with better preoperative preparation, intraoperative navigation, and ultrasound dopplerography. Reconstructive surgery for closing the defect and restoring the blood flow to the artery should be assessed depending on the site of the injury and the anatomical features of the ICA.

The surgical management of intraoperative intracranial internal carotid artery injury in open skull base surgery—a systematic review

“…In the last decade, multiple studies comparing different haemostatic techniques and agents for different types of lesions have led to the implementation of management protocols. [23,73,75,78,89] Unfortunately such studies are lacking for open skull base surgery.…”

“…[77] Although the management of ICA injuries during endoscopic skull base surgery has been extensively discussed, literature on managing this during open surgery is sparse. [2,23,75,78,79] Therefore, our primary aim was to perform a systematic review to give an overview of the different surgical options when dealing with a carotid or large vessel injury during open skull base surgery.…”

Beware of epistaxis: fatal pseudoaneurysm rupture 30 years after treatment of acromegaly

“…Adjuvant medical treatment leads to remission in approximately half of these patients but the remainder may require radiotherapy or radiosurgery for biochemical control 2. Injury to the cavernous internal carotid artery (ICA) and pseudoaneurysm formation is a rare but well-described acute complication of TSS 3–7. A pseudoaneurysm or false aneurysm is an encapsulated haematoma that results from the disruption of the vessel wall and communicates with the ruptured artery.…”

Internal Carotid Injury during Skull Base Surgery—Case Report and a Review of the Literature

“…The lethality of this injury is approximately 10% [ 1 ]. According to the literature, the incidence of iatrogenic ICA injuries is relatively low, with rates of 0.12–1.1% in transsphenoidal approaches and 4–9% in extended endoscopic approaches for treating skull base pathology [ 2 , 3 , 4 ]. However, the actual incidences are probably substantially higher [ 5 ].…”