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      Management of Carotid Artery Injury in Endonasal Surgery

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          Abstract

          Introduction Carotid artery injury (CAI) is the most feared and potentially catastrophic intraoperative complication an endoscopic skull base surgeon may face. With the advancement of transnasal endoscopic surgery and the willingness to tackle more diverse pathology, evidence-based management of this life-threatening complication is paramount for patient safety and surgeon confidence.

          Objectives We review the current English literature surrounding the management of CAI during endoscopic transnasal surgery.

          Data Synthesis The searched databases included PubMed, MEDLINE, Cochrane database, LILACS, and BIREME. Keywords included “sinus surgery,” “carotid injury,” “endoscopic skull base surgery,” “hemostasis,” “transsphenoidal” and “pseudoaneurysm.”

          Conclusions Review of the literature found the incidence of CAI in endonasal skull base surgery to be as high as 9% in some surgeries. Furthermore, current treatment recommendations can result in damage to critical neurovascular structures. Management decisions must be made in the preoperative, operative, and postoperative setting to ensure adequate treatment of CAI and the prevention of its complications such as pseudoaneurysm. Emphasis should be placed on surgical competency, teamwork, and technical expertise through education and training.

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          Expanded endonasal approach: the rostrocaudal axis. Part I. Crista galli to the sella turcica.

          Arlan Mintz, Carl H Snyderman, Amin Kassam … (2005)
          Transsphenoidal approaches have been used for a century for the resection of pituitary and other sellar tumors. More recently, the standard endonasal approach has been expanded to provide access to other, parasellar lesions. With the addition of the endoscope, this expansion carries significant potential for the resection of skull base lesions. The anatomical landmarks and surgical techniques used in expanded (extended) endoscopic approaches to the rostral, anterior skull base are reviewed and presented, accompanied by case illustrations of each segment (or module) of approach. The rostral half of the anterior skull base is divided into modules of approach: sellar/parasellar, transplanum/transtuberculum, and transcribriform. Case illustrations of successful resections of lesions with each module are presented and discussed. Endoscopic, expanded endonasal approaches to rostral anterior skull base lesions are feasible and hold great potential for decreased morbidity. The effectiveness and appropriate use of these techniques must be evaluated by close examination of outcomes as case series expand.
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            Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa.

            Arlan Mintz, Amin Kassam, Carl H Snyderman … (2005)
            The middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module. The anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region. The expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.
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              Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: indications and limitations.

              Fred Gentili, Salwa A. Ganna, Ali Dehdashti … (2009)
              The traditional boundaries of the transsphenoidal approach can be expanded to include the region from the cribriform plate of the anterior cranial fossa to the foramen magnum in the anteroposterior plane. The introduction of endoscopy to transsphenoidal surgery, with its improved illumination and wider field of view, has added significant further potential for the resection of a variety of cranial base lesions. We review our experience with the expanded endoscopic endonasal approach in a series of 22 patients with anterior cranial base and supradiaphragmatic lesions. From June 2005 to June 2007, the expanded endoscopic endonasal approach was used in 22 patients with the following pathologies: 6 craniopharyngiomas; 4 esthesioneuroblastomas; 3 giant pituitary macroadenomas; 2 suprasellar Rathke's pouch cysts; 2 angiofibromas; and 1 each of suprasellar meningioma, germinoma, ethmoidal carcinoma, adenoid cystic carcinoma, and large suprasellar arachnoid cyst. This study specifically focused on the surgical indications and approaches to these lesions and the surgical results, complications, and limitations associated with this technique. Gross total tumor removal, as assessed by postoperative magnetic resonance imaging, was possible in the majority of patients (73%), with the exception of the craniopharyngioma group, in which only 1 lesion was completely removed. There were no permanent neurological complications except for increased visual disturbance in 1 patient. Other complications included cerebrospinal fluid fistulae in 4 patients (18%) and meningitis in 1 patient (5%). There was no operative mortality. Large lesions, significant lateral extension, encasement of neurovascular structures, and brain invasion in malignant lesions are considered some of the contraindications for this technique. The expanded endoscopic endonasal approach is a promising minimally invasive alternative to open transcranial approaches for selective lesions of the midline anterior cranial base. The avoidance of craniotomy and brain retraction and reduced neurovascular manipulation with less morbidity are potential advantages. Major complications have been few, but there are also limitations with this technique. This approach should be included in the armamentarium of cranial base surgeons and considered as an option in the management of selected patients with these complex pathologies.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Int Arch Otorhinolaryngol
                Journal ID (iso-abbrev): Int Arch Otorhinolaryngol
                Title: International Archives of Otorhinolaryngology
                Publisher: Thieme Publicações Ltda (Rio de Janeiro, Brazil )
                ISSN (Print): 1809-9777
                ISSN (Electronic): 1809-4864
                Publication date (Print): October 2014
                Volume: 18
                Issue: Suppl 2
                Pages: S173-S178
                Affiliations
                [1 ]Department of Surgery - Otolaryngology, Head & Neck Surgery, The University of Adelaide, South Australia, Australia
                Author notes
                Address for correspondence Peter-John Wormald, MD, FRACS, FRCS Department of Otolaryngology, Head and Neck Surgery The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, South Australia 5011Australia peterj.wormald@ 123456adelaide.edu.au
                Article
                Publisher ID: 18S2A1ra
                DOI: 10.1055/s-0034-1395266
                PMC ID: 4399584
                PubMed ID: 25992141
                SO-VID: 168eaead-b220-4585-b0d1-89fdf08d3cfc
                Copyright © © Thieme Medical Publishers
                History
                Categories
                Subject: Article

                Keywords: carotid injury,hemorrhage,sinus surgery,endoscopic skull base surgery
                Data availability:
                Keywords: carotid injury, hemorrhage, sinus surgery, endoscopic skull base surgery

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