Endoscopic Repair of Carotid Artery Injury

Intraoperative injury to the Internal Carotid Artery (ICA) during Endoscopic Endonasal Surgery (EES) of the skull base is a rare and well recognized complication which can potentially be associated with high rates of morbidity and mortality. In the event of a traumatic injury to the ICA during EES, hemorrhage might be massive, difficult to control as the access to the sphenoid sinus is limited and the visual field becomes quickly obscured. Bleeding from this vital artery can become lethal within minutes and even when the bleeding is controlled, permanent neurological deficits frequently persist. 

According to the literature, the risk for injury to the ICA following endoscopic tumor resection is around 1%. Many techniques have been developed to manage ICA injury including controlled hypotension, ipsilateral and contralateral neck pressure, proximal control through neck dissection and distal control, with varying degrees of success.

A 57 years old otherwise healthy woman was referred to our institution due to complaints of intense headaches, speech difficulties and dysphagia for 2 weeks. At physical examination the patient demonstrated slurred speech with tongue deviation towards the left. Neck examination and endoscopic flexible fiber optic were normal, and no other neurological deficits were observed.

The operation was performed under general anesthesia using an intraoperative frameless navigation. The surgery was conducted under electrophysiological monitoring. After inferior turbinate lateralization, middle turbinectomy, middle antrostomy, anterior and posterior ethmoidectomy, posterior septectomy and elevation of a nasoseptal flap, the tumor was exposed in the sphenoid sinus. Using a high speed coarse drill, the rostrum and clival tumor extensions were drilled out. The anterior wall of the sphenoid sinus was removed in order to provide a better access.