Radical Resection Skull Base Lesions Requiring Sacrifice of Internal Carotid Artery: Preliminary Surgical Outcome at a Single Medical Center

Objectives: To evaluate our preliminary surgical outcome of extradural skull base lesions requiring sacrifice of ICA.

Methods: We conducted a retrospective review of patients who had undergone endoscopic radical resection of skull base lesions that necessitated sacrificing the internal carotid artery (ICA). The extent of ICA involvement was categorized into three grades: grade 1 (encasing <50%), grade 2 (encasing >50%), and grade 3 (encasing both ICAs). We assessed various factors, including the underlying pathologies, perioperative ICA management, and surgical outcomes, encompassing disease progression, symptom alleviation, and overall survival.

Results: Fourteen cases with a mean age of 62.1 years were collected for analysis. The pathologies included osteoradionecrosis (ORN) in 9 cases, skull base malignancy in 4 cases, and rhinocerebral mucormycosis in 1 case. The extent of ICA involvement was categorized as grade 1 in 5 cases, grade 2 in 6 cases, and grade 3 in 3 cases. The management of ICAs varied, with 3 cases experiencing spontaneous ICA occlusion with sufficient collateral circulation, 6 cases undergoing intentional occlusion after passing the balloon occlusion test (via preoperative embolization or intra-op planned ligation), and 5 cases requiring extracranial to intracranial bypass surgery after a failed balloon occlusion test (including 2 bilateral cases). The median follow-up duration was 12 months (range: 1–56 months), and no treatment-related mortality was observed. There were three morbidities related to the resection, including cranial nerve paralysis in 2 cases and delayed Internal Carotid Artery (ICA) rupture in 1 case. Additionally, two morbidities (symptomatic bypass occlusion in 1 case and intracranial hematoma in 1 case) were associated with the bypass procedures (28.6%). Following radical resection, the prevalence of severe headaches decreased from 71.4 to 14.3%. However, the incidence of cranial nerve palsy increased from 71.4 to 78.6%. A total of 64.2% (N = 9) of patients had an Eastern Cooperative Oncology Group (ECOG) performance score of 1 or lower. There were four cases of disease progression, all of which were malignant. Among them, three cases resulted in eventual death, with two experiencing uncontrolled cancer regrowth and one developing brain stem necrosis after adjuvant radiotherapy. The 2-year progression-free survival and overall survival rates were 62.9 and 70.0%, respectively. Notably, benign lesions exhibited significantly better survival outcomes compared with malignant lesions (log-rank p < 0.05).

Conclusion: Radical resection of the skull base lesion invading ICA can be performed with no perioperative mortality. Depending on the pathology, a good surgical outcome with acceptable social performance can be expected.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
05 February 2024