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CC BY 4.0 · Indian Journal of Neurosurgery
DOI: 10.1055/s-0044-1790533
Case Report

Intraoperative Incidental Internal Carotid Artery Injury in Extended Endoscopic Endonasal Approaches—Causes, Prevention, and Management: A Technical Note

Manjul Muraleedharan
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Arushi Kumar
2   Department of ENT, Nalanda Medical College, Patna, Bihar, India
,
Ravisankar Manogaran 
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Ashuthosh Kumar
3   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Amit Kumar Keshri
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Vivek Singh
1   Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
,
Raj Kumar
4   Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Abstract

In spite of good anatomical awareness, the position of internal carotid artery (ICA) can be tricky in an intraoperative setup with disease causing very significant distortion of anatomy and shift of carotid artery and its branches. A 45-year-old gentleman presented with complaints of left hemicranial headache and painless progressive vision loss in both eyes (left more than right) for 8 months. A probable clinico-radiological diagnosis of meningioma was reached. Intraoperatively, bleeding occurred from left side ICA, control of which was achieved using a long gauze piece used as conventional nasal pack with crushed muscle beneath the gauze piece along with abdominal fat, which was further reinforced with Surgicel. The parasellar ICA is the most common segment injured. Dehiscent or bulging canal of ICA, presence of pseudoaneurysm, attachment of sphenoid septae to the canal, displacement by the lesion, nonenlarged sella because of small size of lesion or vertically oriented lesions, and vessel wall abnormalities increase the risk of injury. It is very essential to have a preoperative discussion involving the skull base surgeons (neurosurgeons and otorhinolaryngologists), neuroradiologists, and neuroanesthetists regarding the complications expected in the case. In case of ICA bleed, the target should be to achieve a temporary hemostasis. In small tears, cottonoids for pressure and bipolar for cauterization will help stop the bleeding, while in larger tears, giving moderate pressure using crushed muscle and cottonoids to achieve intra-operative hemostasis should be tried. After intraoperative hemostasis, the patient needs to be shifted to angiography suite for endovascular stent placement.

Keywords

carotid injury - skull base surgery - endoscopic endonasal surgery


Publication History

Article published online:
16 September 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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