Urgent cerebral revascularization bypass surgery for iatrogenic skull base internal carotid artery injury

When feasible, the management of iatrogenic internal carotid artery (ICA) injury during skull base surgery is mainly endovascular.

To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible.

We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014.

From 235 procedures, we identified 8 consecutive patients with iatrogenic ICA injury managed with an EC-IC bypass. Injury to the ICA occurred during an endoscopic transsphenoidal surgery (n=3), endoscopic transfacial-transmaxillary surgery (n=1), myringotomy (n=1), cavernous sinus meningioma resection (n=1), posterior communicating artery aneurysm clipping (n=1), and cavernous ICA aneurysm coiling (n=1). Endovascular management was considered first-line treatment but was not successful. All patients received a high-flow EC-IC bypass. At a mean clinical/radiographic follow-up of 19 months (range, 3-36 months), all patients had a modified Rankin Scale score of 0 or 1. All bypasses remained patent.

Iatrogenic injury of the skull base ICA is uncommon but can lead to lethal consequences. Many injuries can be treated with endovascular techniques. However, certain cases may still require a cerebral revascularization procedure.