Management of patients after elective carotid artery resection

Sacrificing the internal carotid artery in infiltrating neck tumours: a study of four clinical cases

Tumour infiltration of the carotid arteries, especially the common carotid artery (CCA) and the internal carotid artery (ICA), is a great challenge in maxillofacial surgery. Cases in which the malignant tumour and/or lymph node is stuck to the carotid artery, especially the ICA, have previously been considered inoperable. Four such cases, two with recurrent metastatic nodal neck masses encasing the ICA, one with aggressive fibromatosis, and one with a carotid body tumour, are described herein. Successful resection of the mass along with the ICA was performed in all cases after a positive balloon occlusion test. All patients made an uneventful recovery with no signs or symptoms of any neurological deficits. In addition, all of the patients were free of disease for the whole postoperative period of 18 months.

Extracranial-intracranial bypass for reconstruction of internal carotid artery in the management of head and neck cancer

Extracranial-intracranial bypass surgery was performed prior to carotid resection in eight patients with head and neck carcinoma that involved the carotid artery near the skull base. Four patients underwent the standard one-stage extracranial-intracranial bypass procedure. A two-stage procedure was performed in the remaining four patients. The procedure first involved an anastomosis between the M3 segment of the middle cerebral artery and the superficial temporal artery, followed by a bypass between the M2 segment of the middle cerebral artery and the internal carotid artery. One of the patients who underwent the standard one-stage extracranial-intracranial bypass procedure suffered an intraoperative infarction. Despite even longer occlusion times of the M2 segment, none of the patients who underwent the two-stage bypass suffered from any serious neurologic consequences. Three of seven patients who underwent the curative operations, survived more than 4 years, however, the remaining patients died within 1 year from recurrence. Our results show that carotid artery resection yields an opportunity for cure. In extracranial-intracranial bypass surgery, the temporary occlusion of the middle cerebral artery may also induce serious ischemia; however, the two-stage extracranial-intracranial bypass procedure appears to minimize the risk.

Management of the carotid artery at the skull base

PURPOSE

To determine appropriate management of benign lesions with significant involvement of the carotid artery at the skull base and present an algorithm for safe treatment of these patients.

MATERIALS AND METHODS

From 1982 to 1999, 115 patients with significant parapharyngeal space masses were treated at our institution. Of these patients, 43 had lesions involving the carotid artery at the skull base and served as the basis for this study. All patients underwent preoperative computed tomography or magnetic resonance imaging scans to determine carotid involvement, and all had preoperative 4-vessel arteriograms and carotid occlusion tests with continuous electroencephalography or neurologic examination monitoring to predict safety of carotid sacrifice.

RESULTS

Of 43 patients, 41 passed carotid occlusion testing and were treated surgically. Of these patients, 33 (81%) underwent resection of their lesions with preservation of the internal carotid artery, 5 (12%) had resection with bypass or reconstruction of the artery, and 3 (7%) had en bloc resections without artery reconstruction. There were no transient or permanent neurologic sequelae in any patient.

CONCLUSIONS

When carotid artery encasement occurs in the setting of benign lesions at the skull base, safe resection with vascular preservation is possible in most cases. If carotid artery resection is necessary, vascular bypass or reconstruction is recommended to minimize neurologic morbidity.