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Coronal CT image showing a bony defect at the lateral recess of right sphenoid sinus with soft tissue density in the right sphenoid sinus.
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Iatrogenic internal carotid artery injury is a catastrophic but uncommon complication of endonasal sinus surgery. We present our experience in managing this emergency situation. A 52-year-old man underwent revision endoscopic repair of recurrent cerebrospinal fluid leak that was complicated with profuse haemorrhage during rem...
Context in source publication
Context 1
... 52-year-old man of Chinese ethnicity, who had endoscopic repair for right CSF fistula due to encephalocele eight years prior, presented with recurrent CSF leak on the ipsilateral side ( Fig. 1) and underwent revision endoscopic repair under general anaesthesia. Leak was observed from previous site at lateral recess of right sphenoid sinus. A left Hadad's flap was raised and postero-superior septectomy was performed. While removing the anterior wall of sphenoid sinus using Hajek sphenoid punch forceps, it jerked posteriorly ...
Citations
... This is crucial to minimize the risk of inadvertent damage and ensure their preservation throughout the operation. According to the literature, complications of sinus surgery, such as orbital lesion, dural or intracranial injury, and damage to the internal carotid artery, range from 1.3 to 9.3% [14]. Intraoperative injury to the ICA during FESS is a rare but potentially life-threatening complication. ...
Background and Objectives: The internal carotid artery (ICA) is a vascular structure that can be easily injured during sinus endoscopic procedures, and surgeons should be familiar with its anatomic variants. The aim of this study was to describe the anatomical variations in the internal carotid artery in relationship to sphenoidal sinuses, using computed tomography (CT). Materials and Methods: In this retrospective study, we evaluated the variations of the ICA in relationship to sphenoidal sinuses in a cohort of 600 patients who were assessed between January 2020 and December 2022 in ‘Saint Spiridon’ Emergency Hospital, Iasi, Romania. Descriptive statistics were used to characterize our data. Results: The most prevalent anatomical variant was represented by intrasinusal septa with posterior insertion on the ICA (58.6%), followed by procident ICA (58%) and dehiscent ICA (52%). We could not find any statistical significance regarding demographic characteristics among groups. Conclusions: A thorough CT examination should be performed before functional endoscopic sinus surgery, with the identification of anatomical variants of the ICA, in order to prevent its injury with potentially fatal consequences.
... It could have serious consequences if such inaccurate indication of landmarks occurs near vital structures. If the intersinus septum was attached to the internal carotid artery during transsphenoidal surgery, it can be led serious injury when its removal 16) . In contrast, if the septum was attached farther with a few millimeters, the risk would be decreased, significantly. ...
Total knee replacements (TKR) of Titanium (Ti), Ti6Al4V (Ti64) and CoCrMo (CoCr) alloys have exhibited post implantation life spans extending over 15 years; however, their use is limited by loosening, metal wear particle or stress-related bone resorption and mechanical failures. Recently, with the advent of personalized, and patient-specific manufacturing technologies; implant components can be additive manufactured, and the integration of biological and mechanical methods are able to improve clinical long-term compatibilities. The primary aim of this present study is to evaluate the geometrical accuracy of an AM-native and mesh structured rat-femur used by various biocompatible metal. The femurs were scanned using micro scaled computed tomography (micro-CT) and a designed mesh structure. In this study, 3D printing data optimization was performed within the transplant tolerance through finite element analysis between image data, 3D scan data, and 3D printed output from rat femur for biomimetic 3D printing optimization. Through 3D printing using CoCr, pure titanium, and Ti64 alloy, we tried to explore the optimal implanted metal material and design with less morphological error. The materials and implant designs with conditions more similar to those of actual bones were selected for implantation of patient-specific implants, and 3D printing process was applied to post-traumatic fracture repair.
... According to a survey by Rowan et al., more than 20% of skull base surgeons have caused an ICA injury during their careers; therefore, it is assumed that this complication has been underreported in the scientific literature [5]. Good cooperation of a multidisciplinary team consisting of otorhinolaryngologists, neurosurgeons, anesthesiologists, interventional radiologists, neurologists, and physical therapists is fundamental for optimal results [6]. ...
... The algorithm followed in our department is described in Figure 2. For the best results in minimizing morbidity and mortality, a fundamental feature of the algorithm is close cooperation within a broad interdisciplinary team, which comprises otorhinolaryngologists, neurosurgeons, anesthesiologists, interventional radiologists, neurologists, and rehabilitation therapists [6]. ...
... According to cadaver studies, lateral sphenoid sinus wall dehiscence occurs in 4-22% of cases, and the wall is less than 0.5 mm thick in 88% of cases [13,18]. Moreover, in up to 10% of cases, the ICA canal courses within 4 mm of the midline [6]. Insertion of the intersphenoidal septum into the bony ICA canal was anatomically unfavorable in 16.3% of cases, according to Park et al., while, according to Dziedzic et al., 49% of sphenoid sinuses have at least one septum exhibiting involvement with the ICA protuberance [19,20]. ...
Iatrogenic injury of the internal carotid artery (ICA) is a rare, and probably underreported, complication of transnasal endoscopic skull base surgery. Although treatment algorithms have been suggested, there is no definite consensus or guideline for the management of this severe complication. We describe a case of ICA injury that occurred during a transsphenoidal biopsy of a tumor in the cavernous sinus and we present a treatment algorithm for managing this complication. We reviewed the articles published from 1998 to 2021, reporting on major vascular injury during transnasal endoscopic skull base surgery and endonasal endoscopic surgery, and we compare the methods and results of ICA injury management reported in the literature with the presented case. The most promising treatment for ICA injury might be packing with a muscle graft initially, then performing an endovascular intervention.
... [16,25] V3 (Suboccipital) segment of the vertebral artery that extends from C2 up to the intradural entry is at the maximum risk during surgeries of this region. [26][27][28] C2 isthmus is reported to be small in 23% cases, which increases the risk in trans-pedicle screw insertion. There is a 5.4% variation in the course of V3 segment at level of C1 lateral mass. ...
... In this series, only one patient with ICA injury showed active extravasation during coiling, which was secured by further coiling and parent vessel sacrifice. Lum et al. [26] suggested that patients should be transferred immediately to the neuro-interventional suite after taking temporary measures. [28] Zhang et al. [27] followed their patients with DSA after 1 week at the time of nasal pack removal and after 1 month in their patients of iatrogenic injury. ...
Background:
Major vessel injury is among the most dreaded complications of any neurosurgical procedure. Once intraoperatively tamponaded, it can present in the form of pseudoaneurysm, dissecting aneurysm or complete occlusion of vessel. These injuries are often associated with very high morbidity and mortality. The literature available on this topic is limited and our understanding remains limited.
Objective:
In this article, we present our surgical experience with iatrogenic aneurysms and present a review of literature.
Methods and material:
We conducted a retrospective analysis of all patients with major vessel injury during surgery from a prospectively maintained database from January 2012 to February 2020.
Results:
A total of 15 patients developed iatrogenic aneurysms following a major vessel injury during various neurosurgical procedures. The most common vessel injured was vertebral artery (n = 9) in craniovertebral junction (CVJ) anomalies and ossification of posterior longitudinal ligament (OPLL) followed by internal carotid artery injury (n = 5) in sellar and parasellar pathologies. One patient developed basilar artery injury during endoscopic third ventriculostomy (ETV). Eight patients had pseudoaneurysm and seven had dissecting aneurysm with or without complete thrombosis of the involved artery. A total of two patients died after vascular injury and remaining thirteen patients survived and discharged.
Conclusions:
The adage "prevention is better than cure" applies most aptly in such cases. Any major vessel injury should be followed by immediate angiography and subsequent early management. The endovascular management is more favorable as these aneurysms are difficult to clip due to the absence of a neck and fragile wall.
... The inter-sinus sphenoid septum may deviate off the midline and has an insertion into the internal carotid artery bony canal (Figure 33) or the optic canal. To avoid avulsion of the bony wall, excessive traction on the septum should be avoided in these cases especially in endoscopic pituitary surgery [31]. ...
Anatomical variations of the sinuses are common and may lead to obstruction to the ventilation and drainage of the sinuses. This may lead to osteomeatal complex disease refractory to medications. A preoperative CT of the paranasal sinuses acts as road map guide to identify vital anatomical variations and its relationship to the orbit, skull base, neurological and vascular structures, to prevent iatrogenic injuries. To control intraoperative bleeding, it is critical to identify the anterior and posterior ethmoidal artery indentations and sphenopalatine artery in the anterior and lateral nasal walls. It is essential for the surgeon to familiarize with the anatomy of the ethmoid region, lateral nasal wall, sphenoid sinus, sella and parasellar region and pterygopalatine/infratemporal fossa before embarking on these approaches. The advent of CT scans and state-of-the-art FESS instrumentation has made surgery of the paranasal sinuses less of a mystery for the surgeon. Therefore, identifying and addressing these anatomical variations during FESS is crucial in restoring ventilation and drainage.
... The insult of the carotid artery (as any other hemorrhage) is immediate, unlike cerebrospinal fluid (CSF) leakage which can be delayed and under low pressure. Other insults that can happen to the carotid artery are vessel spasm, thrombosis, pseudoaneurysm formation, and finally carotid-cavernous fistula [7,8]. ...
... In the works of literature, no standard protocols have existed for management [6][7][8][11][12][13]. We shall represent our review of the current management ideas previously reported. ...
... Many methods were tried to save the catastrophic situation and ICA ligation was one of them. Carotid artery ligation is not a wise decision as to its principle [7,36,37]. Generally, in endoscopic pituitary surgery, the dominance of ICA is not in question. Hence, ligation can lead to remarkable stroke and death. ...
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.
... The massive bleeding is hard to manage in EES because it is a one-hand technique in most cases, and the bleeding reduces visibility in the surgical field by dirtying the tip. 2 Approaches for immediate management of ICA injuries are nasal packing, endoscopic clipping, bipolar coagulation and intraoperative angiography. [3][4][5] The aim of this report was to describe a technique to first line emergency treatment of ICA injuries during EES by using Foley urologic catheters. ...
... Incautious surgical maneuvers in the sphenoid sinus and anterior skull base can lead to a damage of ICA. 3 Chin et al. 5 recently described all possible surgical interventions in case of ICA rupture, reporting nasal packing (72%) using various material (Surgicel, cottonoid, Merocel), endoscopic clip sacrifice (16%), bipolar cautery (8%). ...
Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are rare life-threatening events. We describe a technique to manage ICA injuries based on the use of Foley catheters.A 26-year-old female underwent endoscopic transnasal trans-sphenoidal removal of pituitary adenoma. Cerebrospinal fluid leak occurred 4 days postoperatively. During repair procedure, accidental injury of ICA occurred. Emergency nasal packing through positioning of four Foley urologic catheters was successfully performed to stop bleeding. The patient did not report neurologic deficits.In author’s opinion, Foley catheters are suitable to obtain immediate bleeding control since they are rapidly available and easily usable.
... Moreover, CT scans allow the differentiation of inflammatory, benign, and malignant sinonasal pathologies [2]. In particular, the identification of potentially dangerous anatomical characteristics, such as the depth of the frontal skull base or the course and bony coverage of the optic nerve and internal carotid artery, are of central importance to minimize the risks of the operation [3][4][5][6][7][8][9]. ...
Background and Objectives: Preoperative planning utilizing computed tomographies (CT) is of utmost importance in functional endoscopic sinus surgery (FESS). Frequently, no uniform documentation and planning structures are available to residents in training. Consequently, overall completeness and quality of operation planning may vary greatly. The objective of the present study was to evaluate the impact of a structured operation planning (SOP) approach on the report quality and user convenience during a 4-day sinus surgery course. Materials and Methods: Fifteen participant were requested to plan a FESS procedure based on a CT scan of the paranasal sinuses that exhibited common pathological features, in a conventional manner, using a free text. Afterwards, the participants reevaluated the same scans by means of a specifically designed structured reporting template. Two experienced ENT surgeons assessed the collected conventional operation planning (COP) and SOP methods independently with regard to time requirements, overall quality, and legibility. User convenience data were collected by utilizing visual analogue scales. Results: A significantly greater time expenditure was associated with SOPs (183 s vs. 297 s, p = 0.0003). Yet, legibility (100% vs. 72%, p < 0.0001) and overall completeness (61.3% vs. 22.7%, p < 0.0001) of SOPs was significantly superior to COPs. Additionally, description of highly relevant variants in anatomy and pathologies were outlined in greater detail. User convenience data delineated a significant preference for SOPs (VAS 7.9 vs. 6.9, p = 0.0185). Conclusions: CT-based planning of FESS procedures by residents in training using a structured approach is more time-consuming while producing a superior report quality in terms of detailedness and readability. Consequently, SOP can be considered as a valuable tool in the process of preoperative evaluations, especially within residency.
... Adequate preoperative briefing with the anesthesiologist is therefore suggested in cases with potential ICA injury. Thereafter, the patient should be moved to the angiography room and urgent occlusion test followed by endovascular stenting and/or occlusion should be performed by an interventional radiologist 95,97,98 . As a consequence, the interventional radiology unit should be notified when surgery with non-negligible risk of ICA injury is performed. ...
Quando è indicato un approccio chirurgico multidisciplinare nei tumori naso-sinusali con estensione cranica?
Riassunto: I tumouri nasosinusali includono un ampio spettro di neoplasie caratterizzate da un comportamento biologico eterogeneo e dalla localizzazione in un distretto anatomico critico. Diverse discipline mediche sono coinvolte nella diagnosi e nel trattamento di tali tumori. Una revisione narrativa della letteratura è stata condotta per identificare i ruoli delle specialità chirurgiche che appartengono al gruppo multidisciplinare. La diagnosi e la stadiazione dei tumori nasosinusali richiede la collaborazione tra chirurghi, radiologi e patologi. L’identificazione delle estensioni tumorali critiche è fondamentale per un corretto trattamento. L’intervento chirurgico necessario per la maggior parte dei tumori nasosinusali avanzati può essere eseguito da un team otorinolaringoiatrico con adeguato training. Il contributo di neurochirurghi e di specialisti in chirurgia orbitaria è necessario in scenari selezionati. Nei casi di difetti chirurgici complessi possono essere necessarie strategie ricostruttive multidisciplinari. La collaborazione chirurgica multidisciplinare è essenziale per la gestione delle complicanze nel periodo perioperatorio. Nonostante la chirurgia rimanga il trattamento principale, si sta affermando una vasta gamma di trattamenti non-chirurgici, adiuvanti o esclusivi.
... 1,23,27 Multiple articles describe the use of muscle graft alone or combined with other techniques to control bleeding. 2,22,26,[28][29][30] Undoubtedly, it is interesting to practice the different techniques described above in artificial, animal, or cadaveric models. This increases surgical experience and confidence in surgeons, improving their skills and decision-making capability when a complication of this magnitude takes place. ...
BACKGROUND
One of the most feared and dangerous scenarios that can appear during an endoscopic endonasal surgery (EES) is the iatrogenic injury of the internal carotid artery (ICA). Several methods, along with a variety of outcomes, have been described to deal with this complication. To the authors’ knowledge, this is the first report on the use of a Yasargil-type aneurysm clip to solve an ICA injury, preserving the artery’s patency and having a long-term follow-up. The authors discuss the advantages and disadvantages of other vessel preservation techniques compared with clipping.
OBSERVATIONS
A visually impaired 56-year-old woman was diagnosed with a giant nonfunctional pituitary tumor that invaded the sphenoidal sinus, anterior and posterior ethmoidal cells, and both cavernous sinuses, with suprasellar extension and optochiasmatic compression. The patient underwent EES, and during the final resection phase her left ICA was injured, with massive hemorrhage.
LESSONS
ICA injury during endoscopic skull base surgery carries high mortality and morbidity; it is essential to maintain carotid flow when possible to avoid short-term and long-term consequences. There are several techniques depicted in the literature to deal with this situation. The authors report the use of a Yasargil mini-clip to deal with the injury for a positive outcome: primary hemostasis, vessel preservation, and no postoperative complications.
