Introduction: Internal Carotid Artery (ICA) injury is a rare but severe complication of anterior skull base approaches that necessitates prompt recognition and immediate treatment. There are multiple treatment modalities and techniques for treatment of ICA injury, the most definitive being parent artery sacrifice. Novel endovascular techniques offer comparable results while allowing parent vessel preservation. The authors' purpose a clear and concise algorithm for assessing and treating intracranial ICA injury.
Methods: A retrospective review of 4215 cases from the senior authors’ operative database was performed. Only cases of iatrogenic intracranial ICA injury were evaluated. Based on a literature review of ICA injury and management as well as the current case series a treatment algorithm is proposed.
Results: From the senior authors’ cohort of 4215 cases over 10 years (2006-2016) 20 cases of treated iatrogenic ICA injuries were isolated. Of these 8 were identified as injuries involving the intracranial ICA. Mean age was 49.3 years and follow up was up to 5 years. Four were found to have pseudoaneurysm on initial angiogram, four were noted to have active bleeding or extravasation. Three injuries (2 craniotomies and 1 endonasal approach) occurred in the process of tumor resection. Five injuries occurred during vascular procedures. Four injuries were successfully treated with parent vessel preserving techniques (3 Covered Stents and 1 Pipeline embolization device). Four injuries necessitated ICA sacrifice, with two emergent high-flow bypass. There was one mortality, one parent artery sacrifice and bypass. All parent vessel preserving techniques were well tolerated with minimal morbidity.
Conclusions: Urgent identification and management of internal carotid injury is essential in preventing deleterious outcomes. Although parent artery ligation remains the definitive treatment option, an emphasis on parent vessel preservation should be made when possible.
Patient Care: The proposed treatment paradigm provides attendees with a simple and concise treatment algorithm for a severe surgical complication.
Learning Objectives: Understanding the various modalities of management for intracranial ICA injury and the potential benefit of novel parent vessel preserving techniques. Reviewing the current evidence for parent vessel preserving techniques and their applicability in acute ICA injury.