The surgical management of intraoperative intracranial internal carotid artery injury in open skull base surgery-a systematic review

Optimizing Surgical Management of Anterior Skull Base Meningiomas: Imaging Modalities, Key Surgical Considerations, and Risk Mitigation Strategies

Skull base meningiomas present considerable challenges in surgical management due to their proximity to critical neurovascular structures. Anterior skull base meningiomas encompass olfactory groove, supra- and parasellar, anterior sphenoid ridge, cavernous sinus, and spheno-orbital tumors. The success of surgical resection and the likelihood of complications are influenced by several key factors, including the presence of an intact arachnoid plane, tumor size and consistency, peritumoral brain edema, cranial nerve involvement, vascular encasement, and invasion of critical areas such as the optic canal or cavernous sinus. These factors not only affect the feasibility of gross total resection but also play a pivotal role in determining functional outcomes and postoperative recovery. With the vast array of imaging modalities available, selecting the most appropriate investigations to assess these parameters and tailoring surgical strategies accordingly remain complex tasks. This review examines the critical surgical parameters, identifies the most effective imaging modalities for evaluating each, and provides key insights into how this analysis can guide surgical decision-making, mitigate risks, and minimize complications.

Neuroanesthesiological management of carotid rupture in the endoscopic endonasal approach to the skull base

The medical literature on perioperative anesthesiological care of carotid artery rupture in endoscopic endonasal skull base surgery is practically non-existent. This type of neurovascular injury combines a relatively low incidence with a non-negligible morbidity and mortality. It also requires coordinated multidisciplinary treatment to minimize brain injury induced by inadequate therapeutic management. This article presents a series of clinical recommendations and an algorithm for perioperative neuroanesthesiological care of this serious complication. To prepare them, a group consisting of five neuroanesthesiologists, a neurosurgeon, an otorhinolaryngologist, a neuroradiologist, and a haematologist reviewed the limited literature on anesthesiological care of this complication. In addition, they adapted anesthesiological care in neurosurgical scenarios similar to the treatment of carotid artery rupture during endoscopic skull base surgery.

Management and outcomes of internal carotid artery, anterior cerebral artery, or middle cerebral artery injury during microsurgical approach of the anterior and middle cranial skull base: insights from a systematic review and a case series

Injury of the internal carotid artery (ICA), anterior cerebral artery (ACA), and middle cerebral artery (MCA) are rare but devastating complications during microsurgery of the anterior and middle cranial skull base. We systematically reviewed the current knowledge on ICA, ACA, and MCA injury during skull base microsurgery and performed a multicentric data collection to refine their management. A systematic review of ICA, ACA, and MCA injuries during direct microsurgical approaches to the anterior and middle cranial skull base was performed, using PRISMA-IPD guidelines and using a multicentric case collection. Literature search (French and English languages, PubMed/MEDLINE) was performed from January 1946 to July 2024. 76 adult patients were included (65 adult from literature review, 11 from multicentric case collection). The injury involved the ICA, ACA, and MCA in 38.2%, 39.5%, and 22.3% of cases, respectively. Death related to the artery injury occurred in 22.4% of cases. Injury of the ICA and intraoperative management by occlusive clipping were independent predictors of death related to the arterial injury. Permanent neurological deficit related to the artery injury occurred in 46.1% of cases. Injury of the ICA and permanent artery occlusion were independent predictors of permanent neurological deficit related to the arterial injury. Arterial injury during anterior or middle cranial skull base microsurgery is a dramatic complication. Salvage techniques resulting in the occlusion of the injured artery have higher rates of death and of permanent neurological deficit. Non-occlusive techniques should be preferred, whenever feasible, to manage the injury.

Preoperative Vascular and Cranial Nerve Imaging in Skull Base Tumors

Skull base tumors such as meningiomas and schwannomas are often pathologically benign. However, surgery for these tumors poses significant challenges because of their proximity to critical structures such as the brainstem, cerebral arteries, veins, and cranial nerves. These structures are compressed or encased by the tumor as they grow, increasing the risk of unintended injury to these structures, which can potentially lead to severe neurological deficits. Preoperative imaging is crucial for assessing the tumor size, location, and its relationship with adjacent vital structures. This study reviews advanced imaging techniques that allow detailed visualization of vascular structures and cranial nerves. Contrast-enhanced computed tomography and digital subtraction angiography are optimal for evaluating vascular structures, whereas magnetic resonance imaging (MRI) with high-resolution T2-weighted images and diffusion tensor imaging are optimal for evaluating cranial nerves. These methods help surgeons plan tumor resection strategies, including surgical approaches, more precisely. An accurate preoperative assessment can contribute to safe tumor resection and preserve neurological function. Additionally, we report the MRI contrast defect sign in skull base meningiomas, which suggests cranial nerve penetration through the tumor. This is an essential finding for inferring the course of cranial nerves completely encased within the tumor. These preoperative imaging techniques have the potential to improve the outcomes of patients with skull base tumors. Furthermore, this study highlights the importance of multimodal imaging approaches and discusses future directions for imaging technology that could further develop preoperative surgical simulations and improve the quality of complex skull base tumor surgeries.

Vascular Repair for Iatrogenic Injury during Microsurgical Procedures: Clinical Investigation and Review of 18 Cases at a Single Institution

BACKGROUND

 Intracranial vascular injury (VI) due to surgery is a critical complication that can lead to serious neurologic deficits. To our knowledge, only a few review articles on VI during an operation have been published so far. We retrospectively investigated the type, cause, and measurement of VI during surgery at our institution.

METHODS

 Unexpected VI cases occurred in 18 of 2,228 craniotomy procedures, including 794 aneurysm clippings and 357 tumor resections. We investigated the causes and coping techniques of the VI cases, as well as their full details.

RESULTS

 There were six cases of aneurysm neck tear, one case of sylvian vein injury, and one case of superior trunk perforation during direct clipping. Regarding tumor resection procedures, nine cases of arterial injury and one case of cortical vein injury were extracted. Almost all VIs were caused by carelessness or basic manipulation mistakes. We repaired all these cases with simple placement of suture threads with or without pinch clips, flow alteration using bypass techniques, and in 16 cases no neurologic deficit or deterioration on imaging occurred; however, 3 patients were verified to have ischemic changes on postoperative imaging.

CONCLUSIONS

 Most VIs were directly caused by a simple error and carelessness of an operator or an assistant. Many of these injuries can be avoided if a basic set of rules are followed and remembered during the surgical procedure. However, the surgical procedure involves human work, and errors cannot be eradicated even upon maximum concentration levels. Neurosurgeons should be prepared for an eventual quick repair of an unexpected cerebral VI.

The Role of Internal Carotid Artery Stent in the Management of Skull Base Paragangliomas

Background: After two decades from its introduction in the lateral skull base paraganglioma surgery, the indications and results of preoperative internal carotid artery stenting should be critically assessed. Materials and Methods: Monocentric retrospective study on 26 patients affected by head and neck paragangliomas (19 tympanojugular paragangliomas, 4 carotid body paragangliomas, 3 vagal paragangliomas) preoperatively treated with internal carotid artery stents between 2008 and 2023. The preoperative findings, the intraoperative complications and the final surgical results were analyzed. Results: The stent complication rate was less than 3.1%. Self-expanding highly flexible intracranial nitinol stents were applied. In all cases, it was possible to completely mobilize the internal carotid artery and perform a vascular dissection of the tumor. Gross total tumor resection was possible in 85% of cases. The median follow up was 7.83 y (SD +/- 3.93 y). No local recurrence was observed. Conclusions: The preoperative vascular stent facilitates tumor dissection from the internal carotid artery without risk of vascular damage, helping the surgeon to achieve surgical radicality. The vascular stent is indicated in the case of revision surgeries, circumferential involvement of the vessel and in cases with non-insufficient intracerebral crossflow. Procedural complications, temporary antiplatelet therapy and delay of surgery are the limitations of the procedure.

[Diagnosis and Treatment in frontobasal fractures]

Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.

Strategies to avoid internal carotid artery injury in “sandwich” atlantoaxial dislocation patients during surgery

PURPOSE

To elucidate the anatomic relationship between the internal carotid artery (ICA) and the bony structures of the craniovertebral junction among "sandwich" atlantoaxial dislocation (AAD) patients, and to analyze the risks of injury during surgical procedures.

METHODS

The distance from the medial wall of ICA to the midsagittal plane (D1), the shortest distance between the ICA wall and the anterior cortex of the lateral mass of atlas (LMA) (D2) on the most caudal and cranial levels of LMA and the angle (A) between the sagittal plane passing through the screw entry point of C1 lateral mass(C1LM) screw and the medial tangent line of the vessel passing through the entry point were measured. Besides, the location of ICA in front of the atlantoaxial vertebra was divided into 4 categories (Z1-Z4).

RESULTS

There was a statistically difference between the male and female patients regarding D1, and the difference between D2 at level a and level b as well as angle A between the left and right sides were statistically different (p < 0.05). Ninety-two ICAs (57.5%) were anteriorly located in Z3, 50 (31.3%) were located in Z4, 17 were located in Z2, and only one ICA was located in Z1 in all 80 patients.

CONCLUSIONS

In "sandwich" AAD patients, particular attention should be paid to excessively medialized ICA to avoid ICA injury during trans-oral procedures, and the risk of injuring the ICA with more cranially and medially angulated C1LM screw placement was relatively less during posterior fixation procedures. A novel classification of ICA location was used to describe the relationship between ICA and LMA.

Emergency treatment and anesthesia management of internal carotid artery injury during neurosurgery: Four case reports

BACKGROUND

During skull base surgery, intraoperative internal carotid artery (ICA) injury is a catastrophic complication that can lead to fatal blood loss or secondary cerebral ischemia. Appropriate management of ICA injury plays a crucial role in the prognosis of patients. Neurosurgeons have reported multiple techniques and management strategies; however, the literature on managing this complication from the anesthesiologist’s perspective is limited, especially in the aspect of circulation management and airway management when patients need transit for further endovascular treatment.

CASE SUMMARY

We describe 4 cases of ICA injury during neurosurgery; there were 3 cases of pathologically proven pituitary adenoma and 1 case of cavernous sinus endothelial meningioma. After the onset of ICA injury, all four patients were immediately transferred for endovascular therapy under general anesthesia with vital signs monitored and mechanical ventilation. Three patients were transferred to the hybrid operating room, and one patient was transferred to the catheter operating room. Three patients underwent covered stent implantation, and one patient underwent embolization. All four patients experienced hypovolemic shock and received blood products infusion and vasoactive drugs to maintain stable circulation. After the neurosurgery, one patient was extubated and returned to the ward, and the other three were delayed tracheal extubation and returned to the intensive care unit. One patient died from serious neurological complications after 62 d in the hospital, but the other three showed good clinical outcomes.

CONCLUSION

ICA injury imposes a high risk of massive hemorrhage and subsequent infarction. Immediate treatment is critical and requires interdisciplinary collaboration among neurosurgeons, anesthesiologists, and interventional neuroradiologists. Effective hemostatic methods, stable hemodynamics sufficient to ensure perfusion of vital organs, airway safety during transit, rapid localization and implementation of appropriate measures to occlude the damaged vessel are strong guarantees of patient safety.