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

Intraoperative internal carotid artery (ICA) injury during open skull base surgery is a catastrophic complication. Multiple techniques and management strategies have been reported for endoscopic skull base surgery; however, the literature on managing this complication in open skull base surgery is limited. To perform a systematic review and give an overview of the different techniques described to manage this complication intraoperatively, a systematic review was conducted in PubMed, Ovid Medline, Ovid Embase and Scopus for literature published until July 2021. Titles and abstracts were screened. Studies meeting prespecified inclusion criteria were reviewed in full. PRISMA guidelines were strictly adhered to. Out of 4492 articles, only 12 articles could be included, reflecting an underreporting of open skull base ICA injuries. Multiple techniques can be used depending on the location and size of the injury as well as the surgeon's experience. Described techniques include the following: a primary repair via a micro-suture or nonpenetrating clips; wrapping or plugging; coating; occlusion of the parent artery with or without a bypass; packing with further endovascular management. A treatment algorithm is proposed.

Management of an Internal Carotid Artery Injury During Open Skull Base Surgery With a Crushed Muscle Patch - Technical Note and Lessons Learned

BACKGROUND

Iatrogenic internal carotid artery (ICA) injury is a catastrophic complication in open skull base surgery. There is a lack of information regarding the most appropriate techniques on how to manage this complication.

OBJECTIVE

To highlight the difficulties encountered when an ICA injury arises intraoperatively and discuss the role and the potential pitfalls of the crushed muscle patch in the management of an ICA injury during open skull base surgery.

METHODS

In this technical video, we demonstrate the management of intraoperative ICA injury, which occurred during the resection of a diffuse planum sphenoidale meningioma via a left pterional craniotomy.

RESULTS

When isolation of the defect with temporary clips failed, we opted for a crushed muscle graft to plug the defect. Hemostasis was achieved, but because of prolonged pressure application and "overpacking," the parent vessel was occluded.

CONCLUSION

The crushed muscle patch can be easily applied; however, care must be taken not to "overpack" and occlude the ICA.

Direct Repair of Iatrogenic Internal Carotid Artery Injury During Endoscopic Endonasal Approach Surgery With Temporary Endovascular Balloon-Assisted Occlusion: Technical Case Report

BACKGROUND AND IMPORTANCE

Iatrogenic internal carotid artery (ICA) injuries during endoscopic endonasal approach (EEA) surgeries are associated with a high morbidity and mortality, with few acceptable methods described for repair.

CLINICAL PRESENTATION

A 13-year-old girl with a large anterior and central skull base osteoblastoma incurred an iatrogenic cavernous ICA injury during a staged EEA approach. Intraoperative angiogram was performed with balloon-assisted EEA primary microsurgical repair of the lacerated ICA.

CONCLUSION

By integrating current techniques commonly used in open aneurysm surgeries and in endovascular procedures, we developed a rapid, safe technique to repair an EEA-associated iatrogenic ICA injury.

The pterional approach and extradural anterior clinoidectomy to clip paraclinoid aneurysms

OBJECTIVE

The surgical clipping of paraclinoid segment internal carotid artery aneurysms is considered difficult because of the complex anatomical location and important neighboring structures. Our experiences of pterional craniotomy and extradural anterior clinoidectomy (EAC) to clip paraclinoid aneurysms are reported herein.

METHODS

We present two patients with paraclinoid aneurysms who underwent surgical clipping using pterional craniotomy and EAC. The clinical results and operative techniques were reviewed from the patients' medical records.

RESULTS

EAC improves the surgical field in the suprasellar and periclinoid regions. Clinically, a good outcome was obtained in both cases. No surgical complications directly resulting from the EAC were observed.

CONCLUSION

Favorable surgical results can be obtained with pterional craniotomy and EAC for the clipping of paraclinoid aneurysms. EAC is advocated for the clipping of paraclinoid aneurysms.

Complications of anterior clinoidectomy through lateral supraorbital approach

OBJECTIVE

We reviewed the surgical complications from our recent experience in vascular and tumor patients who underwent anterior clinoidectomy through the lateral supraorbital (LSO) approach.

METHODS

Between June 2007 and January 2011, a total of 82 patients with neoplastic and vascular lesions underwent anterior clinoidectomy by the senior author (J.H.) through the LSO approach. We analyzed the operative videos paying particular attention to the surgical technique used for removal of the anterior clinoid process (ACP) and compared the microsurgical nuances to postoperative complications related to anterior clinoidectomy.

RESULTS

Forty-five patients were treated for aneurysms; 35 patients for intraorbital, parasellar, and suprasellar tumors; and 2 patients for carotid-cavernous fistulas. Intradural anterior clinoidectomy was performed in 67 (82%) cases; in 15 (18%) cases an extradural approach was used. In 51 (62%) cases, ACP was removed completely, whereas in the remaining 31 (38%) a tailored anterior clinoidectomy was performed. Four (5%) patients had new postoperative visual deficits and 3 (4%) experienced a worsening of preoperative visual deficits. Twelve (15%) patients improved their preoperative visual deficits after intradural anterior clinoidectomy. Ultrasonic bone device is a useful tool but may damage the optic nerve when performing anterior clinoidectomy. There was no mortality in our series.

CONCLUSION

Anterior clinoidectomy can be performed through an LSO approach with a safety profile that is comparable to other approaches. Ultrasonic bone dissector is a useful tool but may lead to injury of the optic nerve and should be used very carefully in its vicinity.

Anterior clinoidectomy: Description of an alternative hybrid method and a review of the current techniques with an emphasis on complication avoidance

BACKGROUND

Anterior clinoidectomy is a difficult but important part of surgery for a variety of parasellar, proximal carotid and central skull base pathologies. First developed intradurally nearly 60 years ago, the promotion of an extradural technique decades later offered an approach with a different set of difficulties, risks and benefits. Many recent studies have demonstrated that there is no consensus about the "correct side" of the dura from which to remove the anterior clinoid process in a number of pathologies. Here, we review and compare the current techniques for intra- and extradural clinoidectomy and describe a hybrid alternative technique.

METHODS

We used a hybrid method to potentially engage the advantages of the intradural and extradural techniques. The hybrid method starts with an extradural sphenoid wing osteotomy to the level of the superior orbital fissure (SOF). The dura is then incised parallel to the sphenoid wing lateral to the SOF, and the need for further bony removal, including clinoidectomy, is assessed after gentle elevation of the frontal lobe and release of cerebrospinal fluid through opening the optico-carotid cisterns and inspection of the pathology in relation to the clinoid. Sylvian fissure may be dissected to relieve retraction on the frontal lobe.

RESULTS

The hybrid method allows an early identification of the optic nerve and its protection during clinoidectomy. The operator leaves the dura medial to the SOF intact and the clionoidectomy proceeds in an extradural fashion while intradural inspection periodically is performed to assess the extent of necessary extradural bony removal.

CONCLUSION

The hybrid method theoretically can be used as a versatile method under some circumstances. Cutting the dura along the sphenoid wing will prevent the dural layers from obscuring the clinoid and offers intradural visualization to monitor the lesion and potentially tailor bony removal.

Microsurgery for Previously Coiled Aneurysms: Experience With 81 Patients

BACKGROUND:

Residual and recurrent intracranial aneurysms after endovascular treatment with Guglielmi detachable coils may necessitate a microsurgical occlusion.

OBJECTIVE:

To analyze the microsurgical technique and describe how the location, morphology, and appearance of the coiled aneurysm affect the technique.

METHODS:

We retrospectively analyzed 81 patients with 82 previously coiled aneurysms treated microsurgically at 2 Finnish neurosurgical university hospitals in Helsinki and Kuopio between July 1995 and August 2009. Seven videos were selected to demonstrate the microsurgical strategy in various locations.

RESULTS:

Fifty-eight aneurysms (71%) were located at anterior circulation and 24 (29%) at posterior circulation. Fifteen patients were operated on within the first month (early surgery) after coiling, whereas 66 were treated later (late surgery). Complete or partial removal of coils during surgery may facilitate clipping, but is significantly (P < .001) more difficult to accomplish in late surgery. Removal of coils may also increase the chance of poor outcome. Chance of poor outcome also increased with intraoperative aneurysm rupture, size of the aneurysm, and posterior circulation location. Good clinical outcome (same or better clinical condition 3 months after surgery) was achieved in 71 patients (88%). After microsurgery, 4 patients were severely disabled and 6 patients died, 3 of them because of poor clinical condition.

CONCLUSION:

Complete microsurgical occlusion of the residual aneurysm is possible. However, in large or giant aneurysms direct microsurgery is a challenging high-risk procedure, and we recommend that these patients be referred to a dedicated neurovascular center to minimize surgical complications. Even in experienced hands, use of different bypass procedures may be the best option for demanding growing lesions, especially those in the posterior circulation.