Carotid injury -Management in both Anterior & Lateral skull base

Carotid injury
23-1-2017
9.08 pm

For Other powerpoint presentatioins
of
“ Skull base 360° ”
I will update continuosly with date tag at the end as I am
getting more & more information
click
www.skullbase360.in
- you have to login to slideshare.net with Facebook
account for downloading.

Prepartion of this
PPT also contributed
by
Dr. Narendra Kumar
Veerasingamani
MS(ENT) DLO.
with Prof.Ugo Fisch
INDIA

Carotid rupture video – click
https://youtu.be/6SC6clYn
wPY

BEST PROTOCOL , I
have ever seen so
far – BY Dr.Paul
Gardner
---- copy &
paste & see in
any picture
software

Regarding anterior skull base when there is
rupture of carotid only 3 options are
1. Covered stents 2. Clamping 3. Coilling .
Covered stents which can be passed into parasellar
carotid told to me by vascular neurosurgeon – This
is a big boon to anterior skull base approach –
Several seniors opinions has to be taken regarding
longterm effects of these stents
http://www.ncbi.nlm.nih.gov/pubmed/25415067

Benign with recurrence esp.of post RT or malignancy with radical resection when Balloon
Occlusion test fails first we must do ECA-ICA anastomosis . This ECA-ICAanastamosis done by
pterional /FTOZ approach & tumor can be removed by same approach or combined with
endoscopic endonasal or trans-temporal skull base approaches . We shouldn't go only by
endoscopic endonasal without ECA-ICA anastomosis because there won't be cross circulation
if ICA ruptures . Leads to catastrophie. Check others at " Carotid injury " PPT & "Decision
making of anterior & lateral skull base " PPT at www.skullbase360.in

first thing we have to check BOT .
• 1. If cross circulation is not there there is no point in going for
surgery . So direct Shunting has to be done . Surgery has to be done
after 6 - 8 weeks .
• 2. If cross circulation good we can proceed for surgery with muscle
patch & interventional radiologist ready . Even then there are
higher chances of death .
• 3. So in revisions & post radiotherapy especially chordomas cases
pre-op carotid coilling which completely occludes the carotid has to
be done . Then you have to remove tumor . Even then in children it
gives false sense of security . In adults we can safely remove tumor .
Even then if the rent is more than 1.5 cm coilling may come out .
But this is absolutely safe procedure
• I will write /update in detail in few days

1. Acromegaly
2. Post -irradiated
3. Revision
4. Fibrous
5. Chondroma & chondrosarcoma
6. Bromocriptine therapy
Above are potential factors for carotid rupture
So pre-operatively we have to check
1. Ballon occlusion test ( BOT )
2. BOT under hypotention - hypotention because once there is
carotid rupture the patient has to sustain cross flow under
hypotention ( so interventional radiologist checks cross flow
under hypotention pre-operatively in operation theatre )
3. Venous return less than 2 to 3 seconds
4. Color dolplar of brain with cross flow
5. In USA xenon test etc etc are there
If all these are satistfied that case is BOT is passed

If BOT is NOT passed
1. Anterior skull base is contraindicated . " Carotid locking " means
proximal & distal control of carotid possible only in lateral skull
base ( Pterional / FTOZ ) .
2. First shunting has to be done by pterional / FTOZ approach
3. Tumor resection in any skull base has to be done after 2 to 3
months once shunting flow is satisfied , even excision of diseased
carotid can be done

If BOT is passed
we have to do coiling of carotid & proceed by anterior skull base
approach . Even then coiling gives false sense of security . Suppose
if the carotid rent is more than 1 cm it may become a
unmanageable situation

4 . Without pre-op coiling , with or without BOT if you proceed anterior skull
base approach you have 3 options if carotid rupture occurs
a) Muscle plug -very difficult sometimes
b) Covered stent -means like our coronary bypass stent flow is patent
inside of stent . But make sure that your interventional radiologist is
capable to pass in parasellar carotid or not . Sometimes passing covered
stent is difficult to pass in C-shaped parasellar carotid. More over there
are chances of migration of covered stent to origin of opthalmic artery &
risk of blindness . So pre-operatively we have to check ECA - OA (
opthalmic artery ) anastamosis by middle meningeal artery ( MMA ) .
Then even if the covered stent ( or coiling ) migrates & occludes
ophthalmic artery nothing happens ( means blindness won't come ) .
Therere are instances where post-operative pseudo-aneurysms includes
parasellar carotid including the origin of opthalmic artery . Then we must
block opthalmic artery origin also which is above UDR ( upper dural ring ) .
Then pre-operatively we have to check ECA - OA anastamosis by MMA or
else blindness comes .
With covered stents we have to give life long aspirin . Prof. Mario Sanna
pre-operatively pass covered stents in these high risk cases & do
subadvential dissection of carotid after 1 to 2 months of passing covered
stent . In this 1 to 2 month neo-intima forms & even if you do
subadvential dissection rupture won't happens

c) Direct permanent clamping by aneurysmal clamps . If you don't
check BOT pre-operatively & unluckily if that patient has to NO
cross flow , that patient lands up in hemiplegia or death . Luckly if
that patient has sufficient cross flow nothing happens .
With this lucky situations in our career of previous experiences we
should not presume that nothing happens with direct permanent
aneurysmal clamping & I don't check BOT & with my skills I can
peel off tumor . So pre-op BOT under HYPOTENTION is a must in
all carotid encircled tumor cases especially high risk carotid
rupture cases ( if 2 or 3 factors present it is even more riskier
status like for example acromegaly & post-irradiated )
Even we peel of tumor in high risk cases there are high chances of
carotid aneurysms post-operatively [ sometimes carotid micro-
aneurysms present pre-operatively ] & regular followup is
necessary & again at that time BOT & coiling is a must .

5. Even in JNAs revision we have to do pre-operative coiling
especially post-irradiated & in children
6. Always patient safety is more important than our surgical skills &
must follow carotid management principles

JNA surgery by 4 corridors approach - by Dr.
James K. Liu - I feel this 4 corridor is safest
surgery for intracavernous & intracranial
extension JNAs rather than removing only by
nose. Orbitozygomatic transcavernous gives
proximal & distal control of ICA . Endoscopic
Caldwell-Luc ( Tranasmaxillary ) preserves Nose
anatomy – see video
https://www.youtube.com/watch?v=ekwOfEmH
GWg&feature=youtu.be

Prof. Laligam Sekhar says - When the ICA is
invaded or encased by tumor, two controversies
continue to rage.
1. The first is whether one should attempt to
skeletonize the vessel by removing tumor or
whether the vessel should be resected.
2. The second concerns the question of
whether all patients should be
revascularized, or only those whose collateral
circulation is demonstrated to
be limited.

Whether or not the ICA should be left intact
depends on the surgeons attitude and the nature of
the tumor. Benign tumors other than meningiomas
(e.g. schwannoma, pituitary adenoma) may usually
be dissected from the ICA. With meningiomas,
however, encasement and narrowing of the ICA
frequently indicates that the vessel wall has been invaded by tumor. This has
been conrmed by histological
study of removed arteries [19]. Therefore,
total resection often requires ICA resection. Of
course, the surgeon may choose to leave tumor
behind and treat it with radiosurgery. Generally,
chordomas and chondrosarcomas can be dissected
from the ICA, but some require replacing the artery
with a bypass graft. With slowly growing malignant
tumors such as adenoid cystic carcinomas, total
tumor removal requires resection of the ICA-CS.
Furthermore, resecting and replacing the artery encased
with tumor allows the surgeon to give the task
of preserving cranial nerves his full attention.

Should a revascularization procedure be
performed in every patient where tumor
resection creates jeopardy for the ICA, or only in
those who fail preoperative balloon-occlusion
testing? This is a hotly debated issue, but the
occurrence of stroke even when excellent
collateral circulation is present convinces us that
a bypass should be performed every time tumor
resection places the ICA at risk.

Our [ Prof. Laligam sekhar ] patients also
undergo cerebral angiography.
Collateral circulation and tolerance to temporary
occlusion is assessed by compressing the
ipsilateral common carotid while injecting
contrast material into the contralateral ICA and
the dominant vertebral artery. We no longer
perform balloon occlusion tests since we
revascularize all patients in whom ICA
resection or injury seems likely.

When considering sacrifice of the ICA, either
1. electively because of tumor involvement or as an
2. emergency following an accidental injury,
the adequacy of the brain blood supply after exclusion of the artery
has to be assured before the sacrifice. In such clinical scenarios the
patient should undergo six-vessel angiography with BTO applying
radiological, clinical, and functional perfusion criteria to evaluate the
cerebrovascular system.
If a patient does not tolerate vessel occlusion, generally there are two
ways to maintain brain blood supply:
1. revascularization by a bypass or
2. stenting of the ICA.

Management of carotid artery
injury in anterior skull base
- Reference from PJ Wormold

• In Aldo Stamm book it is mentioned that while
managing the Internal carotid artery - " Suture
repair is possible ,albeit technically difficult
and in most instances impractical . "
http://books.google.co.in/books?id=5dczLBfol
BcC&pg=PP7&dq=aldo+cassol+stamm&hl=en
&sa=X&ei=iM85UoeeNYOtrAehwYHIAQ&ved=
0CDsQ6wEwAg#v=snippet&q=Suture%20repai
r%20is%20possible%20%2C%20albeit%20tech
nically%20difficult&f=false

• Saleem Abdulrauf Dear Dr Murali, you are indeed correct,
it is essentially impossible to get complete control of the
ICA through a standard ant skull base approach. The Lateral
approach, with extra-dural exposure of the ICA (petrous
segment) just below GSPN and just post to V3 allows ample
proximal control. I do not recommend operating on any
tumor that is wrapping the ICA without proximal and distal
control. If there is a hole in the ICA, DO NOT try to bipolar
it, it will make the whole bigger. In this situation, a proximal
and a distal temporary clips to be placed, and then use a 9-
0 prolene to suture. If not experienced in micro-suturing,
then place a sundt clip, which is a circling clip that covers
the hole and leaves the parent vessel open.

Incidence
• The incidence of carotid artery injury in
endoscopic sinus surgery is rare, with only 29
case reports described in the literature.
• The incidence is higher in transsphenoidal
pituitary surgery at 1.1% and higher still in
extended endonasal approaches, such as for
craniopharyngiomas, clival chordomas, and
chondrosarcomas, at 5 to 9%.8

Anatomy
• The bony wall overlying the ICA is less than 0.5
mm thick and is not sufficient to protect the
artery.
• some authors also describing the distance
between both ICAs within the sphenoid to be
as close as 4 mm.

High risk
• Factors such as
1. previous radiotherapy,
2. revision surgery,
3. bromocriptine therapy, and
4. acromegaly
5. Chondroid tumors [ chordoma, chondrosarcoma ]
are helpful to identify the at risk patient.
• These patients may warrant preoperative
assessment of collateral cerebral circulation if
their risk is deemed high enough.

Chondroid tumors [ chordoma, chondrosarcoma
] have the greatest risk of ICA injury, and
preoperative carotid balloon test occlusion
should be considered for these tumors when
there is significant ICA involvement.
Must read paper “ Carotid Artery Injury During
Endoscopic Endonasal Skull Base Surgery:
Incidence and Outcomes ” - - -
6 - try to get the this paper from www.sci-
hub.bz or www.sci-hub.cc

Tumors Involving the Cavernous
Segment of the Internal Carotid Artery
1. Meningiomas in this region tend to be supplied by branches of the
ICA in contrast to the usual supply from external carotid branches.
Taken together, in these patients assessment of cerebral blood
flow and, if necessary, preparation for revascularization
procedures prior surgery of the lesion itself are mandatory.
2. A transcranial approach can provide superior vascular control and
m ay be preferable if a large-to-giant fibrous tumor.
3. Extension into the cavernous sinus region, which happens in
about 6 to 10% of cases, may exert pressure on the cranial nerves
III, IV, V, and VI, resulting in oculomotor dysfunction, ptosis,
trigeminal neuralgia, or diplopia. Clinical signs are mostly absent in
tumors that involve the ICA; even complete encasement of the
vessel does not necessarily result in functional flow impairment or
neurological deficits.

To get any paper of any journal free click
www.sci-hub.bz or www.sci-hub.cc
How to get FREE journal papers in www.sci-hub.bz or www.sci-hub.cc
1. When same paper published in different journals , the same paper has
different DOIs -- so we have to try with different DOIs in www.sci-
hub.bz orwww.sci-hub.cc if one of the DOI is not working.
2. If the paper has no DOI , copy & paste URL of that paper from the main
journal website . If you can't get from one journal URL try with different
journal URL when the author publishes in different journals .
3. Usually all new papers have DOIs . Old papers don't have DOIs . Then
search in www.Google.com . Old papers are usually kept them free in Google
by somebody . Sometimes the Old papers which are re-published will have
DOIs. Then keep this DOI in www.sci-hub.bz or www.sci-hub.cc
4. Add " .pdf " to title of the paper & search in www.Google.com if not found
in www.sci-hub.bz or www.sci-hub.cc

Method
Step-1. Two surgeons are engaged, allowing one surgeon to control the
bloodstream, directing it away from the endoscope, while the other obtains
visualization to attempt hemostasis (►Fig. 1).

Step-2.
Two large-bore (10F) suction devices and, if
available, a lens cleaning system for the
endoscope should be used. Or…..

Step-3. The second surgeon uses suction
downside the nose with predominant bleeding
to direct flow away from the other side

Step- 4. The primary surgeon places the
endoscope down the contralateral side, using
the posterior septal edge as a shield from the
blood flow.

Step- 5.
The primary surgeon clears blood ahead of the
endoscope using the second suction device. A
pedicled septal flap should also be cleared and
pushed into the nasopharynx.
Step-6.
The second surgeon is then free to “hover” the
suction device directly over the site of injury to
help gain visualization for the primary surgeon.

Hemostasis can be…
• Emergency ligation in the neck- it causes stroke or even
death.
• Nasal packing
• Ipsilateral common carotid artery compression.
• Bilateral common carotid artery compression with
concurrent surgical widening of the sphenoid sinus
ostium, to facilitate nasal pack placement.
• Packing agents are teflon and methyl methacrylate
patch, fibrin glue, Gelfoam, oxidized cellulose packing
thrombin-gelatin matrix, oxygel, and glue and muslin
gauze.

Muscle patch
The crushed muscle patch was the only method that
succeeded in gaining hemostasis in all instances.
In the clinical setting, muscle is harvested from the
thigh (usually prepared for fascia lata graft in skull base
cases) or sternocleidomastoid in the neck.
A 2 1.5 1-cm graft is harvested then crushed between
two metal kidney basins and, after gaining control of the
surgical field, it is placed directly over the injury site with
Blakesley forceps (►Fig. 2).

Muscle patch
• It should be placed with enough force to stay in
contact with the vessel injury site but should not
compress or occlude the vessel, and it may take
up to 12 minutes to gain hemostasis.
• If the carotid is likely to be exposed to the nasal
cavity, the muscle patch should be reinforced
with an overlying septal flap.
• If the vessel is intracranial, the patch should be
secured with oxidized cellulose and fibrin glue.

Direct vessel closure
• Valentine et al used of U-clip anastomotic device
to repair the injury site after clamping with a
Wormald endoscopic vascular clamp and found
it to be very effective in gaining hemostasis in an
animal model of carotid catastrophe.
• Padhye et al studied different carotid injury
types and their long-term complications and
found that a T2 Aneurysm Clip was able to gain
hemostasis in all injury types as well as prevent
pseudoaneurysm occurrence in an animal model
of carotid bleeding (►Fig. 3).

Endovascular Techniques
• In some patients, hemostasis may not be achievable,
and in these cases urgent transfer for endovascular
intervention must be sought. These interventions are
designed to either occlude the vessel or maintain
vascular flow
• Endovascular occlusion of the artery is generally
performed using a balloon or coil and should be
performed at the wall defect to prevent extravasation
of blood from both anterograde and retrograde vessel
filling.
• Deployment of an endovascular balloon or coil can be
associated with distal migration due to the high-
pressure, high-flow environment of the artery.

Balloon occlusion test (BOT)
• In addition to angiography, balloon occlusion test
of the ICA in combination with
electroencephalogram, transcranial Doppler,
xenon-CT, and single-photon emission computed
tomography are useful to assess the collateral
circulation.
• BOT may not always be possible in the emergency
situation, where hemostasis has not been achieved
and occlusion intervention may be the only way to
save a patient’s life.
https://www.youtube.com/watch?v=EGNgCN1
fUdQ

BTO decision-making algorithm to indicate extracranial–
intracranial bypass surgery:
a) Patients who exhibit neurological deficits or demonstrate an asynchronous
filling of the transverse sinus >1 second will need revascularization with a
large-caliber graft.
b) Patients demonstrating >50% decrease in baseline perfusion will qualify for
a medium or large caliber graft.
c) Patients with 30 to 50% decrease in baseline perfusion will need a small
caliber bypass.
d) In patients with <30% reduced baseline perfusion, the cerebrovascular
reserve capacity should be assessed by acetazolamide stimulation. If the
increase is impaired, a small caliber bypass is recommended.

Currently, an angiographic assessment of the
balloon test occlusion alone is considered
insufficient to reliably identify patients that are
at increased risk for stroke, and therefore need
revascularization prior to sacrifice of the ICA.
This is primarily due to a false-negative rate of
the test of 10 to 15%. Consequently, additional
direct or indirect monitoring of cerebral
perfusion has been suggested.

When considering sacrifice of the ICA, either electively because of
tumor involvement or as an emergency following an accidental injury,
the adequacy of the brain blood supply after exclusion of the artery
has to be assured before the sacrifice.
In such clinical scenarios the patient should undergo a six-vessel
angiography with BTO applying radiological, clinical, and functional
perfusion criteria to evaluate the cerebrovascular system.
If a patient does not tolerate vessel occlusion, generally there are two
ways to maintain brain blood supply: revascularization by a bypass or
stenting of the ICA.

Types of extracranial–intracranial
bypass:
a) Standard /low flow bypass : STA-MCA bypass: the frontal or parietal
branch of the superficial temporal artery is anastomosed to a cortical branch
of the middle cerebral artery (blood flow 20–70 mL/min).
b) Intermediate -flow bypass : Radial graft artery interposition between
external carotid artery and the middle cerebral artery (blood flow 60–100
mL/min).
c) high-flow bypass : Saphenous vein graft interposition between external
carotid artery and the middle cerebral artery (blood flow 100–200 mL/min =).
Intraoperative assessment of bypass function should be verified by ICG
videoangiography, neurophysiological monitoring, thermal di usion probe,
and LASCA.
Bypass surgery or stenting and subsequent tumor surgery should be
performed as a two-staged procedure: once the blood flow to the brain is
secured the tumor can be removed in a separate session.

Algorithm for decision making in revascularization surgery for carotid artery sacrifice.
CBF, cerebral blood flow; STA-MCA, superficial temporal artery to middle cerebral
artery.

Stent graft
• An alternative to occlusion intervention is
placement of a stent graft to seal the injury
site and maintain vascular flow. This is,
however, technically challenging to place in
the tortuous cavernous carotid siphon; stent
grafts are also associated with distant
migration as well as ICA spasm.

Postoperative Considerations
• Postoperative care largely involves the prevention
of potential complications of carotid artery injury,
which include pseudoaneurysm formation and
caroticocavernous fistula.
• A pseudoaneurysm is a tear through all layers of
an artery with persistent flow outside the vessel
into a space contained by surrounding tissue. Its
incidence after carotid artery injury can be as
high as 60% and carries with it a risk of rupture
for up to 3 months.
• Therefore prompt identification and treatment is
required for successful longterm management.

Protocols
• Once hemostasis has been achieved
intraoperatively,
• the patient should be transferred for urgent
angiographic investigation to assess the repair
and ascertain if further endovascular
intervention in required.

• If the immediate postoperative angiogram is
normal
• monitor the patient in ICU until the packing is
removed and another angiogram is
performed, usually at 1 week postsurgery.
• If this is again normal, then the angiogram is
repeated at 6 weeks, 3 months, and 1 year.

If pseudoaneurysm is detected,
stent graft placement isolated
endovascular
occlusion of
aneurysm lumen
Surgery
(bypass
or
aneurysmal clipping)
safest option
As extracranial/intracranial surgery has a
relatively high complication rate

Discussion
• several important steps that a surgeon can take
to successfully manage this complication.
• First, optimal preoperative assessment with
preoperative planning for such a potential
complication is important.
• Second, skilled operative maneuvers can
successfully achieve hemostasis.
• Third, postoperative assessments and
comprehensive management of potential
complications will result in the best possible
outcome for the patient.

• Nasal packing has been widely described as
the method of choice; however, overpacking
has been seen to incur its own complications
secondary to compression of critical
neurovascular structures.
• Use of a crushed muscle patch has been
shown to be effective in gaining primary
hemostasis and maintains normal vessel
characteristics in more than one injury type.
However, it has been associated with
destabilization and pseudoaneurysm if used as
the lone treatment.

• If the surgical field permits, direct vessel
closure techniques such as the U-clip and the
T2 aneurysm clip have been shown to be
effective in a sheep model of carotid bleeding.
• The aneurysm clip was not associated with
pseudoaneurysm formation; however,
placement may influence long-term carotid
flow.
• If hemostasis cannot be achieved promptly,
packing and transfer for angiography and
endovascular intervention with balloon, coil,
or stent graft is indicated.

1. Prevention and management of carotid artery
injury is a combination of appropriate patient
selection, surgical competency, and teamwork,
culminating in the formulation and execution of a
surgical plan.
2. In this anxiety provoking situation, the need for
appropriate training cannot be underestimated.
3. In addition to clinical training, targeted vascular
workshops utilizing cadaveric and live animal
specimens will help surgeons acquire technical
expertise as well as skills in teamwork and plan
formulation necessary to gain the most favorable
outcome for the patient.

Prof. Amin Kassam says in bookhttp://books.google.co.in/books?id=16y4UJEHjr8C... " With
pituitary surgery, the ICA is most susceptible to injury at the medial opticcarotid junction
where the parasellar ICA courses medially. Other risk factors for ICA injury include prior
surgery or radiation therapy, anatomical variations, and tumor encasement or displacement
of the ICA. If there is an injury to the ICA, the goals of treatment are to maintain cerebral
perfusion, obtain focal control of the hemorrhage, and transport the patient to angiography
for definitive management of the injury. Contrary to common practice, the blood pressure
should not be lowered to decrease bleeding since this may result in cerebral hypoperfusion.
Neurophysiological monitoring is invaluable in this situation to reflect cerebral perfusion
and establish thresholds for blood pressure. Immediate treatment options include bipolar
electrocauterization,compressive packing, direct suture repair, clip reconstruction, and
ligation of the vessel. If there is a very small laceration or avulsion of an arteriole from
the wall of the ICA, this can be sealed with careful use of bipolar electrocautery. If the
injury is substantial, the hemorrhage is directed up the suction to maintain visualization
while focal packing (cottonoid) at the site of the vascular injury provides temporary control.

If this is effective and neurophysiologic monitoring stable, additional
packing can be placed while the patient is transferred to angiography for definitive
management. If packing does not control the bleeding, it is best to get further control
prior to transfer. While the vessel is compressed with focal packing, additional
bone can be removed to better expose the vessel proximal and distal to the site of
injury. Although direct suture repair is possible, it is technically difficult and may not
be a realistic option. With adequate exposure vessel preservation can be attempted
through aneurysm clip reconstruction (e.g. Sundt- Keys clips). Otherwise, the vessel
can be occluded with additional packing or placement of aneurysm clips. If packing
is used, it needs to be focal so that bleeding is controlled and blood is prevented from
tracking through a craniotomy defect intracranially. The patient is then transported
to radiology for angiographic assessment and treatment. Preservation of blood flow
with a covered stent is technically difficult in the region of the cavernous sinus and
currently not FDA approved; therefore, permanent occlusion with coils is often the
preferred option. Assessment of collateral blood flow is then performed to assess the
risk of ischemic stroke and the potential need for revascularization (bypass).

Management of carotid artery
injury in Lateral skull base
- Reference from Prof.Mario Sanna

Prof.Mario Sanna - Management of
great vessels in Lateral skull base –
lecture – click
https://www.youtube.com
/watch?v=7tW3Ev9siCs&fe
ature=youtu.be

Modalities of surgical management of
the ICA include:
1. Skeletonization
2. Displacement
3. Subperiosteal/subadventitial dissection
4. Dissection and resection after permanent
balloon occlusion
5. Subadventitial dissection after reinforcement
with stent

1. Skeletonization
This is done in tumors reaching but not adhering to the
artery. The most common lesions are represented by
petrous bone cholesteatomas and type C1 glomus
tumors. The artery can be exposed in certain approaches
to provide proximal control, e. g. the infratemporal fossa
approach or the modified transcochlear approach type A.
In the middle fossa transpetrous approach the artery is
one of the anatomical boundaries that are skeletonized to
avoid injuring while drilling the petrous apex.
Skeletonization carries little risk in experienced hands. An
exhaustive knowledge anatomy is mandatory; a large
diamond burr parallel to the course of the artery is used
to remove the last shell of bone covering the artery.

2. Displacement
Displacement is used
to gain access, e. g.,
during an
infratemporal fossa
type B approach to
the petrous apex .
Displacement should
be done gently and
complete liberation of
the artery is needed
first.
A case of right clival chordoma. The vertical
internal carotid artery (ICA) is gently displaced to
allow proper control of the petrous apex (PA) lying
medial to the artery.

3.Subperiosteal/Subadventitial Dissection
Subperiosteal/subadventitial dissection is accomplished for
tumors that involve the ICA to a greater extent, such as C2
glomus tumors and meningiomas (Fig. 15.24a, b). In general,
dissection of the tumor from the artery is relatively easier
and safer in the vertical intrapetrous segment, which is
thicker and more accessible than the horizontal intrapetrous
segment.
A plane of cleavage between the tumor and the artery
should be found first. In most cases, the tumor is attached to
the periosteum surrounding the artery. Dissection is better
started at an area immediately free of tumor. Aggressive
tumors may, however, extend even to the adventitia of the
artery and subadventitial dissection may be needed. This
should be done very carefully in order to avoid any tear to the
arterial wall, which can become weakened (Fig. 15.25), with
the risk of subsequent blowout.

A case of left glomus jugulare tumor in our early experience.
Subadventitial dissection has been performed because the artery had
been so weakened after the tumor removal. Although the patient had no
relevant complications postoperatively, such excessive manipulation is
better avoided and permanent balloon occlusion or stenting are preferably
tried preoperatively.

4. Dissection and Resection after
Permanent Balloon Occlusion of the
Internal Carotid ArteryIn patients in whom the tumor is adjacent to the carotid artery, the
preoperative examination to determine whether the carotid artery has to be
resected is a crucial and difficult task that can lead to false-negative and false-
positive results.
Carotid artery invasion is difficult to assess even at operation: often the tumor
obscures a portion of the carotid artery or completely surrounds it; malignant
tumors, by their infiltrative nature, do not allow for their separation from the
ICA; manipulating vascular tumors can increase the difficulty, as bleeding
impairs visualization.
When the carotid artery has been controlled by balloon occlusion these
problems are lessened but not eliminated.
Dissection of the occluded ICA is started the cervical level; after isolation, the
artery is ligated immediately after the proximal balloon; then dissection and
separation from the tumor proceeds fromthe vertical petrosal segment until
the junction between horizontal petrosal and lacerum segments; finally,

thanks to the presence of a balloon in the cavernous segment,
the petrous portion of the artery is resected, possibly with a
portion of tumor adherent to it, and sent for pathological
examination . Indeed only after serial sections of the
suspected arterial segment are made can a determination be
made whether there has been vascular invasion.
Despite the lack of carotid wall infiltration, removal of these
tumors and of the adventitia can significantly weaken the
carotid wall and lead to blowout; therefore, PBO of the ICA
should be strongly considered in skull base tumors with
massive radiological involvement of the ICA.

5. Subadventitial Dissection after
Reinforcement with Stenting
From a surgical point of view, preoperative stent insertion allows the skull base
surgeon to perform subadventitial dissection of the ICA with a significant reduction of
the surgical risk.
In the presence of an intraluminal stent, in fact, the surgeon is usually able to establish
a cleavage plane reaching the external surface of the stent, so removing all the
involved portion of the arterial wall. At the same time, the presence of the metallic
net of the stent represents protection against accidental rupture; this is particularly
true when working at the level of the carotid genu and the horizontal segment of the
petrous ICA. In this area the surgical room and the mobility of the artery are reduced
and direct control of the medial wall is particularly demanding, increasing the
difficulty and the risk of surgery. The thickness of the struts of the stent, which
determines its rigidity and its resistance to crushing, can offer different surgical
sensations: although surgical dissection in the presence of thicker stents has seemed
more comfortable, it has been possible without surgical problems even in the
presence of softer stents.

https://www.youtube.com/watch?v=7tW3Ev9siCs –
watch video of Prof. Mario sanna
-

Medication schedule associated with
stenting into the internal carotid artery

Changes of anatomy of the internal carotid artery after stent
insertion. One month after the stent insertion, the neointimal
layer is developed and subsequent subadventitial dissection can
be safely performed.

Dissection usually starts at the cervical level, away
from the tumor, where it easier to find the correct
cleavage plane and proceed distally; the
anteromedial wall of the artery is considered the
most difficult to manipulate because direct
visualization requires bony decompression and
anterior displacement of the intrapetrous segment
of the ICA. The unsolved surgical problem remains
the medial wall of the ICA at the level of the
anterior foramen lacerum, until now unreachable
with the available surgical approaches.

The plane of dissection between the internal carotid artery and the overlying periosteum is best
developed at the entrance of the artery into its canal.
C basal turn of the cochlea (promontory) , ICA internal carotid artery
P periosteum

a Intraoperative view of the balloon used to permanently
occlude the internal carotid artery. b, c Schematic drawings showing
the permanent balloon occlusion of the internal carotid artery. MCA
middle cerebral artery. BA basilar artery. ACA anterior cerebral artery.
OA ophthalmic artery.

a, b Schematic drawings showing the stent reinforcement of
the internal carotid artery. MCA middle cerebral artery. BA
basilar artery. ACA anterior cerebral artery. OA ophthalmic
artery.

JNA classification based on vascular
supply to tumor – by Amit keshri

JNA selection of approach
discussion
https://www.facebook.com/groups/3
47913135290330/permalink/575333
442548297/

Mario sanna lateral skull base book
Sacrifice of the Internal Carotid Artery (Figs. 8.46−8.49)
The internal carotid artery can be sacrificed in the rare
cases in which the artery is markedly encased by the
tumor with subsequent stenosis or in cases with fragile
wall of the artery due to previous surgery or irradiation. A
preoperative balloon occlusion test is mandatory. If the
test shows that the artery can be safely sacrificed, a
permanent balloon is left to close the artery (Figs.
8.46−8.49). In our early practice, carotid resection was
performed more frequently; with time, we have adopted
a less aggressive attitude for fear of long-term
consequences.

Videos of carotid injury & its
management
• https://www.youtube.com/watch?v=deDNqRS
4-OI
• https://youtu.be/HZ2j8BSRLzc

My understanding
With the pretext " DON'T CROSS THE NERVES " in endoscopic skull base , anterior skull base
surgeons trying to remove tumor lateral to parasellar carotid . But this don't cross the nerves
won't stand in lateral transtemporal skull base or neurosurgical skull base . Since ages
neurosurgeons and lateral skull base surgeons removing the tumor lateral to parasellar carotid
by anterior medial & anterio-lateal & parkinson traiangle Or they don't hesitate to cut V2 & V3
. Moveover these lateral approaches have GREATEST control over the carotids . The remaining
tumor medial to the parasellar carotid can be removed by endoscopic aproach [ combined
approach – click http://www.slideshare.net/muralichandnallamothu/combined-approaches-
of-skull-base-360 ]
If there is any rupture of parasellar carotid you can't even pass the stent also & it may
occlude the opthalmic artery . But recently Covered stents which can be passed into
parasellar carotid told to me by vascular neurosurgeon – This is a big boon to anterior skull
base approach –Several seniors opinions has to be taken regarding longterm effects of these
stents
So to my understanding it is always better to have pterional approach exposure ready & then
remove the parasellar tumor by endoscopic or combined especially in revison , fibrous & post-
RT cases . If there is rupture of cavernous carotid , you can do SHUNT procedure by pterional
exposure. If there is no cross circulation preoperatively even Pterional approach is risky.

This distal & proximal carotid control
is called “ CAROTID LOCKING ” –
possible only in Pterional approach
whether it is Endoscopic pterional or
Microscopic pterional approach –
Not at all possible in anterior skull
base

If there is covered stunt or coiling
migration or intentionally if we want
to cross cranially the opthalmic
artery we have to check whether
there is anastamosis of external
carotid artery [ ECA ] to opthalmic
artery [ OA ] by middle meningeal
artery [ MMA ] - then only we have
to block opthalmic artery - very
important in parasellar tumors

Regarding anterior skull base when there is
rupture of carotid only 2 options are
1. Covered stents 2. Clamping .
But recently Covered stents which can be passed
into parasellar carotid told to me by vascular
neurosurgeon – This is a big boon to anterior skull
base approach –Several seniors opinions has to be
taken regarding longterm effects of these stents

Management of Tumor - Bypass surgery or stenting and
subsequent tumor surgery should be performed as a two-
staged procedure: once the blood flow to the brain is
secured the tumor can be removed in a separate session.
Timing of the tumor resection with respect to bypass surgery is
dependent on which vascularization procedure was indicated and
performed. The greater the complexity time consuming, and
demanding the bypass procedure is, the more likely the resection of
the tumor is planned as second surgery. Location of the tumor and its
complexity, especially with regard to its involvement to the ICA, are
also taken into account. In principle, if two different surgical
approaches have to be used, one for the bypass and another for the
tumor resection, it is prudent to proceed in two stages. Once the
vessel is secured and has been sacrificed, the resection of the tumor
can be performed in a separate session. We believe that two separate
sessions are prudent since both the flow replacement procedure by
bypass creation and the tumor resection are inherently complex and
demanding procedures.

http://neurosurgerynow.com/ - Dr.P. Sai Sudarshan sir told to me
regarding covered stents which can be easily passed in parasellar
carotids which previously I read/thought stents can't be passed
in parasellar carotid

Cavernous carotid foreign body by
Medikeri's superspeciality ENT
center – click
https://www.youtube.com/watch?v=
ONC0OJBaUZs&feature=youtu.be

Discussion
Murali Chand Nallamothu BOT has to be done first
& covered stent has to be passed if an iota of doubt
is there & then only remove the foreign body .
Medikeri's superspeciality ENT center You cannot
put a cover stent in the cavernous carotid boss. It
just won't pass in a normal individual iteslf. Forget
about it when there is a stick sitting inside. Besides
we can't put any stent when there is a infected
foreign body sitting there. The stent will act as a
nidus of infection if we put one now.

Murali Chand Nallamothu Recently I spoke with
interventional neurosurgeon who says covered
stent can be passed in parasellar carotid . If not
able to pass into parasellar carotid due to
foreign body , then pterional approach has to be
selected & prepared for shunts & combined
approach has to be done . This is limitation of
anterior skull base surgery . Satish Jain sir , Iype
Cherian sir can clarify this case scenario
management.

Medikeri's superspeciality ENT center Sir this case came
to me after being seen by a neurosurgeons from an apex
Institute where they dint want to do anything for him.
The patient was roaming around for 2 months with them.
That's why we took this decision that too after confirming
good patency of ACOM & PCOM. I had explained to the
patient about the grave risk but he was so fed up that he
just wanted it to be done. Infact I delayed the procedure
for hope of someone better than me probably a
neurosurgeon performing it. Anyways it was done in good
intent & due to lack of choice for the pt.

Iype Cherian I happened to see this remarkable case because Murali
had invited me to see this. I read all the comments leading to why this
procedure was done. Please understand that this procedure without
carotid control was really pushing ones luck. What was the aim of this
procedure when he already has a lost eye..? How did you know about
the collateral circulation..? What does the DSA look like..? As a
Neurosurgeon, everyone is not trained to do trans cavernous exposure
of the carotid with proximal control. I would be showing this in the
national skull base cadaver workshop, Jaipur in September if you
would be interested...But doing it from the nose especially when you
figure that the carotid is pierced by the foreign body is truly awesome
!! ( I generally do not prefer calling someone stupid, because we all
have been there... ) But my dear Medikeri, please dont ever repeat
this...I am glad and I would consider it very lucky that the patient is
doing fine. Next time ( if there is one) Do it with proximal control and
get help form somebody who knows how to open the cranium..

• Rajinder Kumar The sequence of steps should have
been..DSA, know status of ica , cross compression and
check with bto if he tolerates the carotid clamping. If
he does not tolerate then prior ECA ,MCA bypass first
and then proceed with FB removal or remove it in
angio suit with carotid catheter in place with stents
ready. Mere presence of acom and p com does not
mean anything in real practice. Even now the
pseudoaneurysm is equally big challenge and need to
follow above mentioned steps. However one the less
both were lucky to have good outcome.

For better understanding of carotid
injury PPT must read “ decision
making of skull base” – click
http://www.slideshare.net/muralichand
nallamothu/decision-making-between-
anterior-skull-base-lateral-skull-base-
57570902

Carotid injury -Management in both Anterior & Lateral skull base

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (20)

Similar a Carotid injury -Management in both Anterior & Lateral skull base

Similar a Carotid injury -Management in both Anterior & Lateral skull base (20)

Más de Murali Chand Nallamothu

Más de Murali Chand Nallamothu (20)

Último

Último (20)

Carotid injury -Management in both Anterior & Lateral skull base