Management of carotid artery injury in endonasal surgery

Report on Pseudoaneurysm Caused by Injury of Internal Carotid Artery During Endoscopic Pituitary Surgery and Rebleeding After Treatment With Willis Covered Stent

OBJECTIVE

Report on a case of pseudoaneurysm which was caused by injury of the internal carotid artery (ICA) during endoscopic endonasal surgery (EES), which was followed by rebleeding after treatment with a Willis covered stent.

METHODS

A woman, aged 68, underwent EES for the treatment of a pituitary adenoma. During the surgery, the right ICA was injured, and successfully hemostasis by packed with cottonoid and gelatin sponge. Besides, cerebral angiography was performed in the interventional operating room for the purpose of discovering the formation of a pseudoaneurysm in the cavernous sinus segment of ICA, which was treated with a covered stent. After successfully placing the covered stent, the patient was promptly transferred to the general operating room for the removal of the cottonoid and to address the bleeding once again. The authors employ crushed muscles and cottonoid to locally compress and stop bleeding. Owing to concerns about the risk of rebleeding in the patient, after stent implantation, the patient did not utilize antiplatelet drugs. After the surgery, the patient developed occlusion of the right ICA and massive cerebral infarction in the right hemisphere. Dehydration, anti-infection, rehabilitation, hyperbaric oxygen, as well as related treatments, were given. The cottonoid was removed in EES 2 months postsurgery, and no instances of bleeding were observed. Six months after surgery, the patient had clear consciousness and hemiplegia in the left limb, with a Glasgow Outcome Scale score of 4.

RESULTS

The ICA was injured during EES, which resulted in the formation of a pseudoaneurysm, the Willis stent was adopted for treatment, and there was a risk of rebleeding after the nasal packing (cottonoid, crushed muscles) was removed immediately.

CONCLUSIONS

The ICA was injured during EES after bleeding was controlled by packing with cottonoid, crushed muscles, etc, subsequently, the patient was given intravascular treatment, it is advised to make thorough preparations and, after a suitable period, remove nasal packing in the hybrid operating room to address unexpected situations and unforeseen circumstances.

Navigation-guided transcaruncular orbital optic canal decompression in indirect traumatic optic neuropathy: long-term outcomes

PURPOSE

To determine the surgical outcomes using navigation-guided transcaruncular orbital optic canal decompression (NGTcOCD) and investigate the relationship between visual prognosis. visual evoked potential (VEP), association with DeLano type of optic canal and Onodi cells in patients with indirect traumatic optic neuropathy (TON).

DESIGN

Prospective observational.

METHODS

Fifty-two consecutive patients with indirect TON unresponsive to steroid therapy were divided into three groups where Group I comprised of cases with optic canal fracture who underwent NGTcOCD, Group II without optic canal fracture who underwent NGTcOCD and Group III, no-decompression group who chose not to undergo NGTcOCD. An improvement in visual acuity (VA) at 1 week, 3 months and 1 year and amplitude and latency of VEP at 1 year were considered as primary and secondary outcomes, respectively.

RESULTS

The mean VA improved from 2.55±0.67 and 2.62±0.56 LogMAR at presentation to 2.03±0.96 and 2.33±0.72 LogMAR at final follow-up among Group I and Group II patients, respectively (p<0.001 and p=0.01). Statistically significant improvement observed among both the Groups in VEP amplitude (p=<0.01) and among Group II in VEP latency (p<0.01). Both Group I and Group II patients have better outcomes than patients in no-decompression group. VA at presentation and Type 1 DeLano optic canal were observed as significant prognostic factors.

CONCLUSIONS

NGTcOCD serves as a minimally invasive transcaruncular route to the optic canal which enables ophthalmologists to perform decompression from the anterior-most orbital end under direct visualisation. Patients with indirect TON with or without optic canal fracture and unresponsive to steroid therapy when managed with NGTcOCD have shown comparable and superior outcomes.

The Learning Curve for Endoscopic Endonasal Transsphenoidal Pituitary Surgery: Evaluating Endocrine Outcomes

OBJECTIVE

In South Australia endoscopic endonasal approach (EEA) pituitary surgery has been practiced since 2006, largely by two neurosurgeons with a small fellowship-trained otolaryngology team. The aim of this cohort study was to determine if a "learning curve" can be established over this time period, as represented by structural and endocrine patient outcomes.

METHOD

Retrospective cohort study of patients undergoing EEA surgery between 2006 and 2021 in Adelaide, South Australia at three tertiary teaching hospitals.. Cases were divided by each surgeon and split into groups of sequential 40 cases. Endocrine assessment pre- and post-operatively involved static pituitary and end-organ hormones, with dynamic tests as required, assessed by an pituitary endocrinologist. Each hormonal axis (gonadal, cortisol, thyroid, prolactin and growth hormone) was documented preoperatively and at an early and long term follow up at 1-2 and 12 months, respectively.

RESULTS

The study included a cohort of 443 pituitary adenomas managed with endoscopic endonasal transsphenoidal surgery in a consecutive fashion between two neurosurgeons over 16-years. Gross tumour resection but not visual visual outcomes improved with surgical experience but this outcome may be neurosurgeon dependent. Endocrine outcomes were not consistently improved with experience, but lower rates of hypopituitarism were seen with experience with one neurosurgeon. Average follow up was approximately 5 years, and a minimum follow up of 12 months for all patients.

CONCLUSIONS

We present long term endocrine follow up for patients with functional and non-functional adenomas. Improved rates of gross tumour resection were evident with with surgical experience. However, there was no apparent change in post-operative endocrine outcomes.

Internal carotid artery injury during endoscopic transsphenoidal pituitary surgery: risk factors, management

BACKGROUND

Transsphenoidal surgeons should try to avoid internal carotid artery (ICA) injury but also be prepared to manage it. We analyzed our experience with ICA injury during endoscopic transsphenoidal pituitary surgery and present associated risk factors and a management protocol.

METHODS

We retrospectively reviewed and analyzed the medical records of 1596 patients who underwent endoscopic transsphenoidal surgery for pituitary tumor resection in our institution from January 2009 to October 2022.

RESULTS

Six patients experienced an ICA injury. All received timely and effective hemostasis with immediate direct tamponade followed by endovascular treatment. No serious postoperative complications occurred.

CONCLUSIONS

We proposed a treatment plan for ICA injuries encountered during endoscopic transsphenoidal surgery and described our hemostasis process, methods of endovascular treatment, and means of postoperative follow-up in detail.

Interracial anatomical differences in the transsphenoidal approach to the sellar region

OBJECTIVE

Injury to vascular structures such as the internal carotid artery (ICA) is a rare but catastrophic complication of minimally invasive transsphenoidal surgery. Thorough preoperative planning, and knowledge of anatomical landmarks, such as the intercarotid distance (ICD) reduce this risk. Numerous anatomical studies have been conducted regarding the transsphenoidal approach, but none have taken racial disparities into account.

METHODS

Since differences of the cranium, especially of the skull base exist, we sought to analyze anatomical differences of the sellar region in thin sliced T2-weighted MRI scans of 187 (87 male and 100 female) Asian, African American and Caucasian patients provided by the 'Human Connectome Project' (HCP).

RESULTS

We found significant differences in the ICD between males and females across all races. Furthermore, we found that the ICD was up to 2.4 mm smaller in the Caucasian cohort compared to the African American/Asian cohort.

CONCLUSION

These findings indicate that racial disparities regarding the sellar anatomy should be considered in patients undergoing pituitary surgery.

Major Internal Carotid Artery Injury During Endoscopic Skull Base Surgery: Case Report

Major vascular structures are always at risk during complex skull base surgery, particularly with use of the endoscopic endonasal approach, and intraoperative damage of the internal carotid artery (ICA) can be a devastating complication. Herein, we report a case of a young patient who had a major injury of the left ICA during endoscopic resection of a recurrent petrous bone chordoma. Massive bleeding was controlled by a Foley balloon inserted and kept in the resection area. Urgent angiography revealed a persistent leak from the petrous segment of the left ICA, and the vessel was sacrificed with coiling, since a balloon occlusion test showed good collateral blood flow. The patient woke up from anesthesia without a neurological deficit. Salvage resection of recurrent skull base neoplasms deserves specific attention because of the possibility of major vascular damage. In cases of intraoperative ICA injury, its management requires immediate decisions, and the available possibilities for endovascular therapy should always be considered.

Endoscopic Endonasal Optic Nerve Decompression in a Patient With Invasive Fungal Sinusitis Invasion Into the Orbital Apex: Intraoperative Video and Literature Review

Invasive fungal sinusitis (IFS) is rare but potentially fatal in immunocompromised patients. Orbital extension of IFS can cause visual loss or ophthalmoplegia, and the rate of recovery of visual acuity can be low even after treatment with antifungal agents and sinus surgery. In this case, optic nerve decompression with the endoscopic endonasal approach was successful for the treatment of visual loss in a patient with IFS with orbital apex extension. The authors describe the recovery of visual acuity after optic nerve decompression in a patient with IFS who had exhibited visual loss caused by invasion into the orbital apex. The authors also provide an intraoperative video and literature review.

Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review

The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care.

Development of a management protocol for internal carotid artery injury during endoscopic surgery: a modified Delphi method and single-center multidisciplinary working group

BACKGROUND

Intra-operative internal carotid artery (ICA) injury during transnasal endoscopic surgery is a potentially catastrophic event. Such an injury is life-threatening in the immediate setting, with a reported peri-operative mortality rate of 10%. Nasal packing, muscle patches, direct vessel closure, and endovascular techniques have been described as useful strategies for managing ICA bleeds. The objective of this study was to develop a formalized management protocol for intra-operative ICA injury through engagement with a multi-disciplinary panel.

METHODS

A modified Delphi method including literature review, iterative rounds of stakeholder feedback, and expert panel discussions was used to develop a management protocol for ICA injury during transnasal endoscopic surgery. The 10-person multi-disciplinary panel included otolaryngologists, neurosurgeons, interventional neuroradiologists, anesthesiologists, and operating room nursing staff.

RESULTS

After three rounds of stakeholder engagement with the expert panel, consensus was reached on important elements to include within the protocol. The protocol was divided in three categories: Alert, Control, and Transfer. 'Alert' focusses on early communication with anesthesia and nursing staff. 'Control' focusses on techniques to expose the injury and obtain hemostasis or adequate tamponade. Lastly, 'Transfer' describes the process of contacting neuro-interventional radiology and safely transferring the patient. A one-page handout of the protocol was developed for placement in operating theatres.

CONCLUSION

Due to the life-threatening nature of ICA injury, it is imperative that endoscopic sinus and skull base surgeons are prepared to manage this complication. Using a modified Delphi method with a multidisciplinary expert panel, a protocol for management of intra-operative ICA injury was developed.

The 'muscle wonton' repair - A case series of internal carotid artery injuries at a single Centre during its 10-year experience in endoscopic transsphenoidal pituitary surgery

INTRODUCTION

Although rare, injury to the internal carotid artery (ICA) during pituitary surgery may result in serious morbidity such as stroke or death. This case series explores a single centre's incidence and outcomes of ICA injury during endoscopic transsphenoidal pituitary surgery, discusses the current management options, and introduces the 'muscle wonton' (morcellised muscle wrapped in a single sheet of Surgicel®) as being a viable repair option.

METHODS

All patients undergoing pituitary operations from January 2010 to December 2019 at the Queen Elizabeth Hospital, Birmingham, UK were included. Primary outcome was number of internal carotid artery injuries during pituitary surgery. Secondary outcome measures included pre-operative (demographic, risk factors such as previous radiotherapy, number of previous operations, imaging available), operative (intra-operative image guidance, intra-operative doppler ultrasound, which side ICA was damaged, repair technique) and post-operative result (death, cranial nerve VI palsy, or stroke).

RESULTS

7 out of 893 patients (0.8%) were identified as having an ICA injury. Four of the injuries were left sided. Average age was 54 years old, five were male. In four of the ICA injuries intra-operative navigation imaging was used, and a further two concurrently used ultrasound doppler. Three of the seven cases resulted in permanent morbidity (stroke). There were no other consistent demographic, pre-operative, operative, or post-operative similarities. The two patients with muscle wonton repair suffered no permanent serious complication of ICA injury (i.e. death, abducens nerve palsy, stroke).

DISCUSSION

Our findings resemble the current literature, with left sided ICA injury being more common. Different methods for repairing ICA injury exist, however morcellised muscle patches have shown significant promise in animal models, and the perforated Surgicel® helps create an easy delivery method. The muscle wonton is a viable surgical option for repairing ICA injuries during pituitary surgery.

Injury to the Extrasellar Portion of the Internal Carotid Artery during Endoscopic Transsphenoidal Surgery: A Case Report

Background

Injury to the internal carotid artery (ICA) during endoscopic transsphenoidal surgery (ETSS) is a serious complication with a risk of mortality. ICA injury during ETSS usually occurs during intrasellar manipulations and rarely occurs in the extrasellar portion. Several hemostatic procedures have been proposed for ICA injury in the intrasellar portion, whereas hemostatic methods for ICA injury in the extrasellar portion, where the ICA is surrounded by bone structures, are less well known.

Case Presentation

A 65-year-old man with an incidental pituitary tumor underwent ETSS. The petrous portion of the left ICA was injured during resection of the sphenoid septum connected with left carotid prominence using a cutting forceps. Bleeding was too heavy for simple hemostatic techniques. Hemostasis using a crushed muscle patch was tried unsuccessfully during controlling of the bleeding. Eventually, the injured site of the ICA was covered with cotton patties followed by closing with a vascularized pedicled nasoseptal flap. Cerebral angiography immediately after surgery showed no extravasation from the injured site of the left ICA petrous portion. However, a carotid-cavernous sinus fistula originating from the injured ICA site was detected 7 days after surgery, so the vascular reconstructive surgery combined with left ICA occlusion was performed. The overall postoperative course was uneventful.

Conclusion

We believe that emergency application of the cottonoids may be effective for hemostasis against ICA injury in the extrasellar portion during ETSS, but further vascular reconstruction combined with ICA occlusion on the injured side and removal of the cottonoids would be required.

Establishing a Multidisciplinary Cavernous Carotid Injury Simulation to Train Neurosurgical, Otolaryngology, and Anesthesia Residents

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for technique and algorithm development in resident learners. This study develops a realistic cadaveric model for the training of crisis resource management in the setting of cavernous carotid artery injury. An expanded endonasal approach and right cavernous carotid injury is performed on a cadaveric head. The cadaver's right common carotid artery is cannulated and connected to a perfusion pump delivering pressurized simulated blood. A simulation mannequin is incorporated into the model to allow for vital sign feedback. Surgical and anesthesia resident learners are tasked with obtaining vascular control with a muscle patch technique and medical management over the course of 3 clinical scenarios with increasing complexity. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the learners prior to beginning the simulation. An independent reviewer evaluated the learners on communication skills, crisis management algorithms, and implementation of appropriate skill sets. After each scenario, residents were debriefed on how to improve technique based on evaluation scores in areas of situational awareness, decision-making, communications and teamwork, and leadership. After the simulation, learners provided feedback on the simulation and this data was used to improve future simulations. The benefit of this cadaveric model is ease of set-up, cost-effectiveness, and reproducibility.

Characterization of outcomes and practices utilized in the management of internal carotid artery injury not requiring definitive endovascular management

BACKGROUND

After internal carotid artery (ICA) injury during endoscopic skull base surgery, the majority of patients undergo ICA embolization or stenting to treat active extravasation or pseudoaneurysm development. However, management practices when embolization or stenting is not required have not been well described. The objective of this study was to determine how patients with ICA injury but no embolization, stenting, or ligation do long-term and ascertain the reconstruction methods utilized.

METHODS

Twenty-nine cases of ICA injury were identified in an international multi-institutional retrospective review. Of these, we identified six cases that were not treated with embolization, stenting, or ICA sacrifice. Information was available for five cases.

RESULTS

A muscle patch was used in the immediate repair of each case. A nasoseptal flap was used in one case. Prefabricated nasal tampons were used in all cases. Nasal packing was initially left in for a median of 7 days prior to removal. The initial muscle patch was reinforced with a second muscle graft in one case. One case demonstrated ICA bleeding at the time of packing removal and was repacked an additional week. Follow-up for each of these cases was at least 2 years. No cases of subsequent carotid rupture were found and none of these cases ultimately underwent endovascular stenting. Radiation or proton therapy has not been subsequently used in any of these patients.

CONCLUSIONS

This study details the reconstruction, lessons learned, and long-term follow-up for five cases of ICA injury not treated with embolization, stenting, or ligation.

Identifying Best Practices for Managing Internal Carotid Artery Injury During Endoscopic Endonasal Surgery by Consensus of Expert Opinion

BACKGROUND

Injury to the internal carotid artery (ICA) is a potentially devastating complication of endoscopic endonasal surgery (EES) that as many as 20% of skull base surgeons will experience at least once during their careers. Managing these injuries is difficult given the small operative field and poor visibility created by high-flow hemorrhage, and, at present, there is no consensus regarding best practices.

OBJECTIVE

This study seeks to consolidate the practices and opinions of experienced skull base surgeons from high-volume tertiary care centers into a single consensus statement regarding the best practices for managing ICA injuries during EES.

METHODS

A panel of 23 skull base surgeons (15 neurosurgeons and 8 otolaryngologists) completed a 3-round Delphi survey that assessed experiences and opinions regarding various aspects of ICA injury management. Mean (SD) years since fellowship completion was 15.6 (8.1) and all but 3 surgeons had experienced an ICA injury at least once.

RESULTS

The final consensus statement included 36 guidelines all of which were grouped under 1 of 4 categories: 11 statements concerned preoperative management and equipment for high-risk patients; 14 statements concerned hemorrhage control; 4 statements concerned definitive management; 7 statements concerned pharmacologic treatment, blood pressure, and neurophysiologic monitoring.

CONCLUSIONS

There are numerous decisions that a surgeon must make when facing a carotid artery injury. In our estimation, many questions can be grouped under 1 of the 4 categories outlined in our consensus statement and can be addressed by these findings.

Optoacoustic imaging in endocrinology and metabolism

Imaging is an essential tool in research, diagnostics and the management of endocrine disorders. Ultrasonography, nuclear medicine techniques, MRI, CT and optical methods are already used for applications in endocrinology. Optoacoustic imaging, also termed photoacoustic imaging, is emerging as a method for visualizing endocrine physiology and disease at different scales of detail: microscopic, mesoscopic and macroscopic. Optoacoustic contrast arises from endogenous light absorbers, such as oxygenated and deoxygenated haemoglobin, lipids and water, or exogenous contrast agents, and reveals tissue vasculature, perfusion, oxygenation, metabolic activity and inflammation. The development of high-performance optoacoustic scanners for use in humans has given rise to a variety of clinical investigations, which complement the use of the technology in preclinical research. Here, we review key progress with optoacoustic imaging technology as it relates to applications in endocrinology; for example, to visualize thyroid morphology and function, and the microvasculature in diabetes mellitus or adipose tissue metabolism, with particular focus on multispectral optoacoustic tomography and raster-scan optoacoustic mesoscopy. We explain the merits of optoacoustic microscopy and focus on mid-infrared optoacoustic microscopy, which enables label-free imaging of metabolites in cells and tissues. We showcase current optoacoustic applications within endocrinology and discuss the potential of these technologies to advance research and clinical practice.

Inadvertent internal carotid artery (ICA) injury during transsphenoidal surgery: review of literature

Background

Internal carotid artery (ICA) injury is a hazardous catastrophe for the skull base surgery team. We aimed to illustrate the vital joints in this hazardous event during endoscopic surgery.

Main text

The condition is rare (1.1%) but fatal per se. Working in the field of endoscopic surgery is not free of charges. It demands a thorough knowledge of anatomy, variations, and pathoanatomy to expect what can be seen thereafter. Once the injury occurs, one must have a quite clear plan to proceed. Marvelous bleeding is confusing not only in the field but also in the mind process.

Conclusion

Endoscope teams when expose to this event should think in a stepwise manner. In our review, we explained the pathoanatomy of the field after an injury, pre-conditions of injury, and how to avoid certain drawbacks during management.

Crisis Management Simulation: Review of Current Experience

Crisis management simulation is important in training the next generation of surgeons. In this review, we highlight our experiences with the cavernous carotid injury model. We then delve into other crisis simulation models available for the neurosurgical specialty. The discussion focuses upon how these trainings can continue to evolve. Much work is yet to be done in this exciting arena and we present several avenues for future discovery. Simulation continues to be an important training tool for the surgical learner.

[Combination of pituitary adenomas and intracranial aneurysms]

The combination of intracranial tumors and asymptomatic brain aneurysms is an urgent problem, since it can significantly affect surgical intervention. Aneurysms are common in patients with meningioma, glioma and pituitary adenoma. According to certain authors, combination of aneurysms with pituitary adenomas is 7 times more common than with other tumors. In these cases, a comprehensive examination of the patient and decision-making on surgical strategy are required. This review is devoted to epidemiology, diagnosis and treatment of patients with a combination of pituitary adenomas and intracranial aneurysms detected intraoperatively or at the preoperative stage. The manuscript is illustrated by cases observed at the Burdenko Neurosurgery Center.

Use of Adenosine to Facilitate Localization and Repair of Internal Carotid Artery Injury during Skull Base Surgery: A Case Report and Literature Review

BACKGROUND

Internal carotid artery (ICA) injuries represent a rare, potentially fatal complication of endoscopic endonasal skull base surgery (EESBS). The use of adenosine to induce transient hypotension and facilitate management of high-flow, high-pressure arterial lesions has been well-documented in neuro-endovascular literature. A similar setting in which adenosine-induced hypotension may prove beneficial is during the management of major vascular injury encountered during EESBS.

METHODS

A case of ICA injury and subsequent repair during EESBS is presented.

RESULTS

A 74-year-old female underwent endoscopic transsphenoidal resection for a recurrent pituitary adenoma. During suprasellar resection, the right cavernous ICA was inadvertently injured resulting in brisk bleeding. Immediate vascular tamponade was applied, and a crushed muscle graft was obtained. Two intravenous doses of adenosine were administered in quick succession to produce transient hypotension and facilitate repair of the injury with the graft. Neurovascular imaging revealed a small pseudoaneurysm which remained stable throughout the postoperative course. The patient underwent definitive stent embolization of the pseudoaneurysm 1 month following discharge.

CONCLUSION

Prompt repair of ICA injury during EESBS is crucial, but often limited by poor visualization. Adenosine-induced hypotension has demonstrated great efficacy as an adjuvant in neurovascular clipping of intracranial aneurysms and remains a valuable tool for the endoscopic skull-base surgeon as well. In cases with high risk for ICA injury, adenosine should be readily available.

Perioperative management of endoscopic transsphenoidal pituitary surgery

The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Rupture of Internal carotid artery pseudoaneurysm in the sphenoid sinus as a complication of deep neck space infection

BACKGROUND

Pseudoaneurysm of the internal carotid artery (ICA) is a very rare but potentially fatal complication of deep neck space infection.

METHODS

This paper describes a very rare case of an ICA pseudoaneurysm rupture in the sphenoid sinus caused by a deep neck abscess.

RESULTS

A 62-year-old male with a deep neck space infection underwent surgical drainage. On the postoperative 21st day, however, he suddenly had massive epistaxis. A transnasal endoscopic examination found massive bleeding out of the sphenoid sinus. Immediate intra-arterial angiography revealed two pseudoaneurysms of the left ICA at the cavernous segment (C4) and the clinoid segment (C5), which were embolized with coils. The patient made an uneventful recovery after the embolization.

CONCLUSION

We found no reports in the literature that pseudoaneurysms associated with a deep neck infection rupture in the sphenoid sinus. Prompt treatment along with accurate diagnosis is essential for successful management of such cases. J. Med. Invest. 66 : 188-189, February, 2019.

[Management and complications of tumor resections of the midface]

Only about 8% of head and neck tumors affect the midface. This anatomical area is characterized by an enormous number of functionally important structures, and it is frequently only possible to achieve small resection margin distances. To avoid complications and unfavorable results, a dedicated preparation of both patient and surgeon is warranted. This review aims to provide encouragement for the postgraduate training of interested ENT specialists. Following the clinical course and based on recent literature, strategies to avoid complications of tumor surgery to the midface are given.

Utility of the Vidian Canal in Endoscopic Skull Base Surgery: Detailed Anatomy and Relationship to the Internal Carotid Artery

OBJECTIVE

To investigate key anatomic features of the vidian canal that have a critical role in planning and performing endoscopic skull base surgeries.

METHODS

We reviewed skull base computed tomographic images of 640 consecutive subjects. Studies were analyzed in axial, coronal and sagittal planes.

RESULTS

The mean (±SD) length of the vidian canal was 15.4 ± 2.0 mm in female subjects and 16.6 ± 1.7 mm in male subjects, and the difference between genders was statistically significant (P < 0.001). The most common rostral-caudal course of the vidian canal was medial to lateral and was followed by the straight course, tortuous course, and lateral-to-medial course. The frequency of pneumatization pattern from most common to least common was types 0, III, II and I. Of 342 evaluated sides, the vidian canal was located below the level of the anterior genu of petrous ICA in 303 (89%) sides, at same level with the anterior genu of petrous ICA in twenty-five(7%) sides, and above the level of the anterior genu of petrous ICA in fourteen(4.1%) sides.

CONCLUSIONS

A variety of previously undefined features of the vidian canal that can alter the course of surgical procedure were defined. The position of the vidian canal with respect to the petrous internal carotid artery (ICA) was extensively described. From a surgical standpoint, a working room inferior and medial to the vidian canal might not always be a safe approach, because the vidian canal could be located superior to the level of the anterior genu of petrous ICA according to our findings in the present study.

Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report

Background

Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications.

Case Description

We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention.

Conclusions

This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.

Injury of the Carotid Artery during Endoscopic Endonasal Surgery: Surveys of Skull Base Surgeons

Objectives  This study aimed to review endoscopic skull base surgeon experience with internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) to provide an estimate of the incidence of ICA injury, the associated factors and identify the best training modalities for the management of this complication. Design  Anonymous electronic survey of past participants at a well-established endoscopic skull base surgery course and a global online community of skull base surgeons. Main Outcome Measures  Relative incidence of ICA injuries during EES, associated anatomic and intraoperative factors, and surgeon experience. Results  At least 20% of surgeons in each surveyed population experienced a carotid artery injury. Reported carotid artery injuries were most common during tumor exposure and removal (48%). The parasellar carotid artery was the most commonly injured segment (39%). Carotid artery injuries were more common in high-volume surgeons, but only statistically significant in one of the two populations. Attendance at a skull base course or courses did not change the incidence of carotid artery injury in either surveyed population. In both surveys, respondents preferred live surgeries or active (not computer simulated) training models. Conclusions  ICA injury is underreported and most common when manipulating the parasellar carotid artery for exposure and tumor dissection. Given the high morbidity and mortality associated with these injuries, vascular injury management should be prioritized and taught in a graduated approach by modern endoscopic skull base courses.

Platelet activation by crushed and uncrushed muscle: a flow cytometry analysis

BACKGROUND

Crushed autologous muscle is used in skull base surgery in the acute phase of major arterial hemorrhage to stop bleeding. The mechanism of this is not yet clear, but is thought to involve the formation of a platelet plug, which seals the vessel wall defect but still allows ongoing blood flow to the brain.

METHODS

In this study we use flow cytometry to replicate the in-vivo actions of crushed muscle on platelets in whole blood. We compare the ratio of activation of platelets exposed to crushed and uncrushed muscle supernatant in control patients and in patients on antiplatelet agents.

RESULTS

Crushed muscle activated platelets to a higher degree than uncrushed muscle: 5.18-fold greater in control blood (p = 0.002); 6.53-fold greater in aspirin-exposed blood (p < 0.0001); and 9.4-fold greater in clopidogrel-exposed blood (p < 0.0001).

CONCLUSION

Crushed muscle caused a consistently increased ratio of platelet activation when compared with uncrushed muscle across all groups, adding to the evidence that at least part of its clinical effect is the result of platelet activation.

Endoscopic Management of Cavernous Carotid Surgical Complications: Evaluation of a Simulated Perfusion Model

OBJECTIVE

Endoscopic surgical treatment of pituitary tumors, lateral invading tumors, or aneurysms requires surgeons to operate adjacent to the cavernous sinus. During these endoscopic endonasal procedures, the carotid artery is vulnerable to surgical injury at its genu. The objective of this simulation model was to evaluate trainees regarding management of a potentially life-threatening vascular injury.

METHODS

Cadaveric heads were prepared in accordance with the Oregon Health & Science University body donation program. An endoscopic endonasal approach was used, and a perfusion pump with a catheter was placed in the ipsilateral common carotid artery at its origin in the neck. Learners used a muscle graft to establish vascular control and were evaluated over 3 training sessions. Simulation assessment, blood loss during sessions, and performance metric data were collected for learners.

RESULTS

Vascular control was obtained at a mean arterial pressure of 65 mm Hg using a muscle graft correctly positioned at the arteriotomy site. Learners improved over the course of training, with senior residents (n = 4) performing better across all simulation categories (situation awareness, decision making, communications and teamwork, and leadership); the largest mean difference was in communication and teamwork. Additionally, learner performance concerning blood loss improved between sessions (t = 3.667, P < 0.01).

CONCLUSIONS

In this pilot endoscopic endonasal simulation study, we successfully demonstrate a vascular complication perfusion model. Learners were able to gain direct applicable expertise in endoscopic endonasal techniques, instrumentation use, and teamwork required to optimize the technique. Learners gained skills of vascular complication management that transcend this model.