Endoscopic Endonasal Carotid Injury: Case Series and Review of the Modern Literature with Lessons Learned

Background: Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery (ESBS) is a feared complication that is not well studied.

Objective: To evaluate the incidence and identify potential risk factors in (1) a single-site case series and (2) the modern literature of ESBS ICA injuries and highlight lessons learned.

Methods: Retrospective review of ESBS performed at our institution (1998–2020) identified 18 ICA injuries. Factors predisposing to injury and management were identified. We compared our series to those reported in the literature (last 5 years) via systematic review of the MEDLINE database with search terms: “carotid injury” AND “endoscopic surgery.”

Results: Eighteen ICA injuries, representing an event rate of 0.46% (n = 18/3,889) were recorded. 17/18 cases involved tumors beyond the sella and all were considered level III, IV, or V in complexity. The most frequent location was in the cavernous segment (7, 39%) followed by the paraclival segment (5, 28%). The injury most commonly occurred during tumor dissection (10, 56%). Pathologies included adenoma (5, 28%), chordoma (5, 28%), meningioma (5, 28%), and three others (17%). Five patients (28%) had prior surgery with three (17%) having undergone prior radiation. Bipolar electrocautery was attempted in all cases of ICA injury. Aneurysm clips were additionally used in nine cases (50%) and packing in the remainder. Clipping and packing were combined with a muscle patch in 6 (33%) cases. In fourteen cases (78%), ICA repair was followed by angiogram without subsequent intervention. Of the 4 remaining cases, two (11%) were treated with coil embolization, one (6%) with stent placement, and one (6%) with thrombectomy. At 1-month follow-up, pseudoaneurysm formation was detected in 3 (17%) cases. 12 (67%) cases had no post-op neurological deficit related to ICA injury with 4 having minor deficits at 1-month follow-up and 2 (11%) cases resulted in death.

A systematic literature review revealed 28 manuscripts with 76 patients relevant to this study with variable reporting of injury details. Injuries occurred most frequently in the cavernous segment (33/42, 79%) followed by the paraclival segment (9/42, 21%). Pathologies included adenoma (36/57, 63%), chordoma (17/57, 30%), chondrosarcoma (4/57, 7%), and various others (20/57, 35%). 16/35 (46%) had prior surgery and 6/18 (33%) had prior radiation. Local control was achieved with nasal packing (37/69, 52%), muscle patch (29/69, 47%), or electrocautery (3/69, 4%). 30/75 (40%) patients underwent sacrifice of the ICA, 28/30 (93%) by coil embolization. 16/75 (21%) had a stent placed. 65/76 (86%) patients had no post-op deficits related to ICA injury with 8/76 (11%) having minor fixed deficits and three patients died (4%).

Conclusions: ICA injury during ESBS is an infrequent and manageable complication. Avoidance of brain ischemia remains paramount, but preservation of the vessel remains difficult. If deemed not salvageable, clip ligation is a suitable option. Review of the modern literature had variable reporting but reveals an experience similar to our case series. Operator experience may play a role. We advocate for pre-op risk stratification and multidisciplinary support for management of ICA injury cases (figure).

Fig. 1

Publication History

Article published online:
12 February 2021