Progress in carotid artery surgery at the base of the skull

Abstract

From 1977 to 1984, 752 reconstructions of the supra-aortic arteries were performed at our service. In a group of 31 patients presenting with transient ischemic attacks (13) or minor strokes (15), preoperative multiplane angiograms identified lesions from various causes in extremely high locations (fibromuscular dysplasia, 10; atherosclerosis, 6; traumatic changes, 10; spontaneous dissection, 3; and mycotic aneurysms and others, 4) in 34 internal carotid arteries (aneurysms, 10; and stenosis, 24). Surgery was performed on 30 patients. Flow restoration was achieved by resection and vein graft replacement (20), gradual dilatation (5), thromboendarterectomy (6), and tangential clip for exclusion of a lateral aneurysm (1). Only one patient was treated with an extracranial-intracranial anastomosis because the stenosis extended into the carotid siphon. One patient was treated with heparin. Exposure of the internal carotid artery (ICA) at the base of the skull required dissection of the digastric muscle, careful mobilization of the cranial nerves, and detachment of the styloid process in 29 patients. Partial resection of the mastoid process was helpful in two patients. The carotid bone canal was opened from the lateral side in four cases to allow the most distal anastomosis 1 cm within the carotid canal. Back-bleeding was controlled by a balloon catheter. A shunt was impossible to use and clamping time averaged 62 +/- 40 minutes. Except for one recurrent stroke and two transient ischemic attacks no other neurologic deficits occurred. Cranial nerve damage could not be avoided in 21 cases (nervus recurrens, 7; nervus glossopharyngeus, 16; and nervus facialis, 4) but disappeared clinically within a 1- to 6-month period in all but two. Each surgical patient underwent control angiography, which demonstrated 30 arteries to be patent, two became occluded, and one had an insignificant stenosis. We conclude that standard surgical techniques are unsuitable for repair of highly located lesions of the ICA. Although extracranial-intracranial anastomosis has been proposed in patients with planned ligation of the ICA, the anatomic reconstruction remains advantageous because flow is restored to normal and the source of emboli is eliminated. With the use of a special approach, graft replacement can be performed up to the base of the skull.

Cervical Carotid Artery Dissection

“…2,11,18 This is suspected to be due to its mobility within the neck and fixation at the base of the skull, making it susceptible to strain. 4,19 The wall of an artery consists of 3 layers, the intima, media, and adventitia. 4,19 The wall of an artery consists of 3 layers, the intima, media, and adventitia.…”

Atypical Presentation of Cavernous Sinus Infection with Intracavernous ICA Aneurysm

“…Other common complications include hemorrhage, and thromboembolic complications with neurological sequalae. Computed tomography (CT) was considered superior when compared to magnetic resonance imaging in previous studies however digital subtraction angiography remains the gold standard for diagnosis and determination of specific anatomical details and endovascular management as suggested by Sandmann et al [7]. Connor et al [8] described the definitive treatment of carotid mycotic aneurysm as surgical resection of aneurysm with reestablishment of arterial flow, if possible.…”

Surgical Management of Extracranial Internal Carotid Aneurysms by Cervical Approach

“…Many authors report successful treatment of high‐lying EICAA through a cervical approach, 3,15,27 even construction of a distal anastomosis into the carotid foramen 7,28 . For a small distance into the carotid foramen (4–5 mm), cervical approach is still appropriate and resection of part of mastoid process and vaginal process is necessary 7,28 . For longer distances, other approaches, used by oral surgeons, such as cervico‐petrous, posterolateral and anterolateral are more suitable.…”