Introduction: Carotid artery injury is a well-known complication of anterior skull base surgery, whether microscopic or endoscopic, usually involves the cavernous segment of the carotid artery at the wall of the sphenoid sinus and is usually manifested by a hemorrhagic crisis in the operating room and mandates timely management. We bring here attention to another carotid injury that manifests with the formation of delayed small pseudoaneurysm and which may be unrecognized intraoperatively because of the ease of stopping the hemorrhage and stems from the avulsion or injury to the medial clival meningeal branch.
Methods: We illustrate three cases of carotid artery injury resulting at the medial clival artery describing the intraoperative findings, postoperative course and recommendations for its management.
Results: In each case bleeding was easily controlled with packing but vigilance led to immediate and repeat cerebral angiography. Pseudoaneurysms developed in two patients requiring additional treatment while one patient suffered no sequela and was managed expectedly.
Conclusions: Although hemostasis may be achieved easily and this alone may be all that is needed if a carotid artery injury occurs from the medial clival branch, immediate and delayed angiography is needed to ensure that no pseudoaneurysm develops. In the event of pseudoaneurysm development we advocate for the placement of a covered stent if at all possible as the alternative of carotid artery sacrifice has a high rate of morbidity and mortality even despite a tolerated balloon test occlusion.
Patient Care: Carotid artery injury is a potentially devastating complication of skull base surgery. If this occurs at the medial clival artery it may be overlooked which could lead to an unrecognized potentially fatal pseudoaneurysm. This study aims to heighten the awareness of its occurance and make recommendations on its management.
Learning Objectives: By the conclusion of this session, participants should be able to 1. describe the role of the medial clival branch in carotid artery injuries 2. understand the importance of vigilant surveillance with immediate and repeated angiography 3. understand the benefit of treating this injury endovascularly with a covered stent 4. understand the limitations of treatment with a covered stent 5. understand the risks of carotid artery sacrifice