Skull base approach to carotid artery lesions: technique, indications, and outcomes

Operative approaches to lesions of the carotid artery at the skull base are challenging and place multiple cranial nerves at risk. Herein, we describe a preauricular approach utilizing anterior dislocation of the temporomandibular joint with microscopic drill-out of the medial glenoid and Eustachian tube to identify and skeletonize the carotid artery in the foramen lacerum. The facial nerve remains undissected during this approach. Nine of 10 patients presented with aneurysm, six spontaneous and three following blunt trauma, and one patient presented with carotid artery rupture after penetrating trauma. Three of the patients presented with cranial nerve (CN) deficits that persisted. One patient was unevaluable preoperatively due to trauma but awoke with multiple CN deficits. Only one of nine evaluable patients suffered a new long-term CN deficit (XI). One patient had persistent temporomandibular joint dysfunction. All patients had long-term patency of the graft or anastamosis and no new neurologic symptoms were reported with a mean follow-up of 55 months. Open approaches to the carotid artery at the skull base are feasible and with careful anatomic dissection can be performed with minimal morbidity in most cases. We present full details and images of the operative approach.