Iatrogenic injury of the internal carotid artery (ICA) is a rare, and probably underreported, complication of transnasal endoscopic skull base surgery. Although treatment algorithms have been suggested, there is no definite consensus or guideline for the management of this severe complication. We describe a case of ICA injury that occurred during a transsphenoidal biopsy of a tumor in the cavernous sinus and we present a treatment algorithm for managing this complication. We reviewed the articles published from 1998 to 2021, reporting on major vascular injury during transnasal endoscopic skull base surgery and endonasal endoscopic surgery, and we compare the methods and results of ICA injury management reported in the literature with the presented case. The most promising treatment for ICA injury might be packing with a muscle graft initially, then performing an endovascular intervention.

Department of Clinical Neurosciences Faculty of Medicine University of Ostrava 701 03 Ostrava Czech Republic

Department of Craniofacial Surgery Faculty of Medicine University of Ostrava 701 03 Ostrava Czech Republic

Department of Imaging Methods Faculty of Medicine University of Ostrava 701 03 Ostrava Czech Republic

Department of Neurosurgery University Hospital Ostrava 708 52 Ostrava Czech Republic

Department of Otorhinolaryngology and Head and Neck Surgery University Hospital Ostrava 708 52 Ostrava Czech Republic

Department of Radiology University Hospital Ostrava 708 52 Ostrava Czech Republic

Zobrazit více v PubMed

Chin O.Y., Ghosh R., Fang C.H., Baredes S., Liu J.K., Eloy J.A. Internal carotid artery injury in endoscopic endonasal surgery: A systematic review. Laryngoscope. 2016;126:582–590. doi: 10.1002/lary.25748. PubMed DOI

Padhye V., Valentine R., Paramasivan S., Jardeleza C., Bassiouni A., Vreugde S., Wormald P.J. Early and late complications of endoscopic hemostatic techniques following different carotid artery injury characteristics. Int. Forum Allergy Rhinol. 2014;4:651–657. doi: 10.1002/alr.21326. PubMed DOI

Valentine R., Wormald P.-J. Controlling the surgical field during a large endoscopic vascular injury. Laryngoscope. 2011;121:562–566. doi: 10.1002/lary.21361. PubMed DOI

Usachev D., Sharipov O., Abdali A., Yakovlev S., Lukshin V., Kutin M., Fomichev D., Dorokhov P., Bukharin E., Shkarubo A., et al. Internal Carotid Artery Injury in Transsphenoidal Surgery: Tenets for Its Avoidance and Refit—A Clinical Study. Brain Sci. 2021;11:99. doi: 10.3390/brainsci11010099. PubMed DOI PMC

Rowan N.R., Turner M.T., Valappil B., Fernandez-Miranda J.C., Wang E.W., Gardner P.A., Snyderman C.H. Injury of the Carotid Artery during Endoscopic Endonasal Surgery: Surveys of Skull Base Surgeons. J. Neurol. Surg. B Skull Base. 2018;79:302–308. doi: 10.1055/s-0037-1607314. PubMed DOI PMC

Lum S.G., Gendeh B.S., Husain S., Gendeh H.S., Ismail M.R., Toh C.J., Izaham A., Tan H.J. Internal carotid artery injury during endonasal sinus surgery: Our experience and review of the literature. Acta Otorhinolaryngol. Ital. 2019;39:130–136. doi: 10.14639/0392-100X-1312. PubMed DOI PMC

Gardner P.A., Snyderman C.H., Fernandez-Miranda J.C., Jankowitz B.T. Management of Major Vascular Injury During Endoscopic Endonasal Skull Base Surgery. Otolaryngol. Clin. N. Am. 2016;49:819–828. doi: 10.1016/j.otc.2016.03.003. PubMed DOI

Muto J., Carrau R.L., Oyama K., Otto B.A., Prevedello D.M. Training model for control of an internal carotid artery injury during transsphenoidal surgery. Laryngoscope. 2017;127:38–43. doi: 10.1002/lary.26181. PubMed DOI

Pacca P., Jhawar S.S., Seclen Dv Wang E., Snyderman C., Gardner P.A., Aboud E., Fernandez-Miranda J.C. “Live Cadaver” Model for Internal Carotid Artery Injury Simulation in Endoscopic Endonasal Skull Base Surgery. Oper. Neurosurg. 2017;13:732–738. doi: 10.1093/ons/opx035. PubMed DOI

Hamour A.F., Laliberte F., Padhye V., Monteiro E., Agid R., Lee J.M., Witterick I.J., Vescan A.D. Development of a management protocol for internal carotid artery injury during endoscopic surgery: A modified Delphi method and single-center multidisciplinary working group. J. Otolaryngol. Head Neck Surg. 2022;51:30. doi: 10.1186/s40463-022-00582-w. PubMed DOI PMC

Kassir Z.M., Gardner P.A., Wang E.W., Zenonos G.A., Snyderman C.H. Identifying Best Practices for Managing Internal Carotid Artery Injury During Endoscopic Endonasal Surgery by Consensus of Expert Opinion. Am. J. Rhinol. Allergy. 2021;35:885–894. doi: 10.1177/19458924211024864. PubMed DOI

Ciric I., Ragin A., Baumgartner C., Pierce D. Complications of transsphenoidal surgery: Results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997;40:225–236; discussion 236–237. doi: 10.1097/00006123-199702000-00001. PubMed DOI

Fujii K., Chambers S.M., Rhoton A.L. Neurovascular relationships of the sphenoid sinus. A microsurgical study. J. Neurosurg. 1979;50:31–39. doi: 10.3171/jns.1979.50.1.0031. PubMed DOI

Raymond J., Hardy J., Czepko R., Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am. J. Neuroradiol. 1997;18:655–665. PubMed PMC

Koitschev A., Simon C., Löwenheim H., Naegele T., Ernemann U. Management and outcome after internal carotid artery laceration during surgery of the paranasal sinuses. Acta Otolaryngol. 2006;126:730–738. doi: 10.1080/00016480500469578. PubMed DOI

Gardner P.A., Tormenti M.J., Pant H., Fernandez-Miranda J.C., Snyderman C.H., Horowitz M.B. Carotid artery injury during endoscopic endonasal skull base surgery: Incidence and outcomes. Neurosurgery. 2013;73:261–269; discussion 269–270. doi: 10.1227/01.neu.0000430821.71267.f2. PubMed DOI

Little R.E., Taylor R.J., Miller J.D., Ambrose E.C., Germanwala A.V., Sasaki-Adams D.M., Ewend M.G., Zanation A.M. Endoscopic endonasal transclival approaches: Case series and outcomes for different clival regions. J. Neurol. Surg. B Skull Base. 2014;75:247–254. doi: 10.1055/s-0034-1371522. PubMed DOI PMC

Renn W.H., Rhoton A.L. Microsurgical anatomy of the sellar region. J. Neurosurg. 1975;43:288–298. doi: 10.3171/jns.1975.43.3.0288. PubMed DOI

Park A.H., Stankiewicz J.A., Chow J., Azar-Kia B. A protocol for management of a catastrophic complication of functional endoscopic sinus surgery: Internal carotid artery injury. Am. J. Rhinol. 1998;12:153–158. doi: 10.2500/105065898781390154. PubMed DOI

Dziedzic T., Koczyk K., Gotlib T., Kunert P., Maj E., Marchel A. Sphenoid sinus septations and their interconnections with parasphenoidal internal carotid artery protuberance: Radioanatomical study with literature review. Wideochir. Inne Tech. Maloinwazyjne. 2020;15:227–233. doi: 10.5114/wiitm.2019.85837. PubMed DOI PMC

Sharma R.K., Irace A.L., Overdevest J.B., Gudis D.A. Carotid artery injury in endoscopic endonasal surgery: Risk factors, prevention, and management. World J. Otorhinolaryngol. Head Neck Surg. 2022;8:54–60. doi: 10.1002/wjo2.7. PubMed DOI PMC

Eloy J.A., Svider P.F., D’Aguillo C.M., Baredes S., Setzen M., Folbe A.J. Image-guidance in endoscopic sinus surgery: Is it associated with decreased medicolegal liability? Int. Forum Allergy Rhinol. 2013;3:980–985. doi: 10.1002/alr.21210. PubMed DOI

Sunkaraneni V.S., Yeh D., Qian H., Javer A.R. Computer or not? Use of image guidance during endoscopic sinus surgery for chronic rhinosinusitis at St Paul’s Hospital, Vancouver, and meta-analysis. J. Laryngol. Otol. 2013;127:368–377. doi: 10.1017/S0022215113000261. PubMed DOI

Laws E.R. Vascular complications of transsphenoidal surgery. Pituitary. 1999;2:163–170. doi: 10.1023/A:1009951917649. PubMed DOI

Sylvester P.T., Moran C.J., Derdeyn C.P., Cross D.T., Dacey R.G., Zipfel G.J., Kim A.H., Uppaluri R., Haughey B.H., Tempelhoff R., et al. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: Case series and review of the literature. J. Neurosurg. 2016;125:1256–1276. doi: 10.3171/2015.6.JNS142483. PubMed DOI

Alicandri-Ciufelli M., Maccarrone F., Botti C., Pavesi G., Presutti L. Use of Foley catheter in control of internal carotid hemorrhage during endoscopic endonasal surgery. Folia Med. 2021;63:809–814. doi: 10.3897/folmed.63.e56461. PubMed DOI

Fastenberg J.H., Garzon-Muvdi T., Hsue V., Reilly E.K., Jabbour P., Rabinowitz M.R., Rosen M.R., Evans J.J., Nyquist G.N., Farrell C.J. Adenosine-induced transient hypotension for carotid artery injury during endoscopic skull-base surgery: Case report and review of the literature. Int. Forum Allergy Rhinol. 2019;9:1023–1029. doi: 10.1002/alr.22381. PubMed DOI

Kassam A., Snyderman C.H., Carrau R.L., Gardner P., Mintz A. Endoneurosurgical hemostasis techniques: Lessons learned from 400 cases. Neurosurg. Focus. 2005;19:E7. doi: 10.3171/foc.2005.19.1.8. PubMed DOI

Determining the manner of death in victims in drug-induced psychosis: a case of an atypical head stab wound