Sphenoid sinus septations and their interconnections with parasphenoidal internal carotid artery protuberance: radioanatomical study with literature review.

Abstract

Introduction: Internal carotid artery (ICA) injury is the most dangerous and life-threatening complication in patients operated on due to parasellar tumors via a minimally invasive endoscopic endonasal approach. Sphenoid septal attachment to the ICA protuberance within the sphenoid sinus was found to be one of the anatomical risk factors for ICA injury during transsphenoidal surgery. Aim: To determine the relationship between the sphenoid sinus septa and the parasellar or paraclival internal carotid artery prominence based on our own material and a literature review. Material and methods: The axial plane scans of computed tomography angiography and a literature review of previously published papers on the septum variation and its connection with the ICA prominence are provided. Results: Out of 100 sphenoid sinuses, 49 (49%) had at least one septum inserted at the ICA prominence. In the majority of cases 42 (86%) one septum was inserted at the prominence of one of the ICAs. In 7 (14%) cases, two separate septa were inserted at the prominences of both ICAs. Patients with multiple septa and those having an incomplete septum were at higher risk of at least one of them being inserted at the ICA prominence within the sinus. Including cases from the literature review, the average number of septa per patient was 1.42. The risk of intersection between the septum and the ICA prominence was 32%. Conclusions: A significant percentage of the intrasphenoidal septa are inserted at the sphenoidal ICA protuberance.

Risky anatomical variations of sphenoid sinus and surrounding structures in endoscopic sinus surgery

“…During ESS, care must be taken not to fracture these septa as this may have catastrophic consequences such as uncontrollable bleeding, retrobulbar hematoma, proptosis and diplopia [ 1 , 25 ]. It has been reported that only one in four IS are located in the midline [ 26 ]. In our study, IS was deviated in 60.4% of individuals: in 30.1%, it was attached onto the ICA protuberance and in 14.3% into the ONC protrusion.…”

“…In our study, IS was deviated in 60.4% of individuals: in 30.1%, it was attached onto the ICA protuberance and in 14.3% into the ONC protrusion. Poirier et al [ 27 ] reported attachment of the IS onto the ICA in 3.4%, Batra et al [ 28 ] in 37.5% and Dziedzic et al [ 26 ] in 49% of cases. In our work, we identified that 30.4% presented AS similar to levels reported by Anusha et al [ 16 ] Jaworek-Troc et al [ 29 ] reported that AS were present in 78.0% of cases, similar to levels reported by Akgül et al [ 17 ].…”

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

“…Moreover, in up to 10% of cases, the ICA canal courses within 4 mm of the midline [ 6 ]. Insertion of the intersphenoidal septum into the bony ICA canal was anatomically unfavorable in 16.3% of cases, according to Park et al, while, according to Dziedzic et al, 49% of sphenoid sinuses have at least one septum exhibiting involvement with the ICA protuberance [ 19 , 20 ]. During a resection, twisting and pushing movements can cause a bone fragment to injure the ICA wall.…”

Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase

“…36 Obviously, the rule of thumb is to prevent these injuries by proper training and operator experience, using the "2 surgeons, 4 hands" method, and having a good grasp of patientspecific anatomy utilizing the best preoperative imaging techniques. 30,[37][38][39][40][41][42][43] Anatomical considerations in EES must be kept in the mind to avoid this serious complication. [44][45][46] However, ICA injury may still occur in the best of hands, 47 and apart from exsanguination, this injury may lead to a diverse range of vascular findings such as pseudoaneurysms, arterial spasm, arterial thrombosis/emboli, and caroticocavernous fistula formation.…”