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

Abstract

Intraoperative internal carotid artery (ICA) injury during open skull base surgery is a catastrophic complication. Multiple techniques and management strategies have been reported for endoscopic skull base surgery; however, the literature on managing this complication in open skull base surgery is limited. To perform a systematic review and give an overview of the different techniques described to manage this complication intraoperatively, a systematic review was conducted in PubMed, Ovid Medline, Ovid Embase and Scopus for literature published until July 2021. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full. PRISMA guidelines were strictly adhered to. Out of 4492 articles, only 12 articles could be included, reflecting an underreporting of open skull base ICA injuries. Multiple techniques can be used depending on the location and size of the injury as well as the surgeon's experience. Described techniques include the following: a primary repair via a micro-suture or nonpenetrating clips; wrapping or plugging; coating; occlusion of the parent artery with or without a bypass; packing with further endovascular management. A treatment algorithm is proposed.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution

“…A recent review on managing ICA injuries in skull base surgery also mentioned wrapping or-in worst case scenarios-tamponading. 1,8 However, these suggestions are derived from the anatomical peculiarities of ICA including the following: (1) difficulty of proximal control-it must be prepared in advance via a cervical incision; (2) high blood flow posing a high mortality risk due to large amounts of bleeding when injured; (3) large diameter and ease of access for endovascular management; and (4) existence of the circle of Willis-the majority of patients can tolerate the loss of unilateral ICA. Therefore, the best way to deal with injury to intracranial, somewhat peripheral, arteries or veins is unknown.…”

“…Although VI of the internal carotid artery (ICA) during endoscopic and open skull base procedures is well documented, [1][2][3][4][5][6][7][8] not all of the techniques might be applicable to intracranial small VI. To the best of our knowledge, only a few cases have been favorably dealt with the injury to the intracranial, somewhat peripheral, vessels during microsurgical intracranial operation.…”

“…To overcome unexpected VIs in various situations, it is important to identify in advance the conditions in which VI is more likely to occur and the various available techniques to cope with it. Although VI of the internal carotid artery (ICA) during endoscopic and open skull base procedures is well documented, [1][2][3][4][5][6][7][8] not all of the techniques might be applicable to intracranial small VI. To the best of our knowledge, only a few cases have been favorably dealt with the injury to the intracranial, somewhat peripheral, vessels during microsurgical intracranial operation.…”

Early postoperative cognitive decline—are there any preventive strategies for surgical patients in the emergency setting?

“…Changes in brain functional connectivity has been related to both peripheral nerve block and spinal anesthesia as a result of deafferentation on pain sensitivity [75,76]. In regard to choosing the right intravenous anesthetic agent, there is no current answer given by literature [77]. Although none of them has proven a significant benefit in preventing postoperative cognitive impairments, a possible neuroprotective effect was attributed to propofol [77].…”

“…In regard to choosing the right intravenous anesthetic agent, there is no current answer given by literature [77]. Although none of them has proven a significant benefit in preventing postoperative cognitive impairments, a possible neuroprotective effect was attributed to propofol [77]. As for volatile anesthetics, there are some studies which suggest a favorable cognitive outcome when using volatile agents like sevoflurane or desflurane, or at least indicate them to be a safer alternative for patients with preexisting cognitive disorders [66,[78][79][80].…”