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

BACKGROUND: When feasible, the management of iatrogenic internal carotid artery (ICA) injury during skull base surgery is mainly endovascular. OBJECTIVE: To propose a cerebral revascularization procedure as a rescue option when endovascular treatment is not feasible. METHODS: We retrospectively reviewed all extracranial-intracranial (EC-IC) bypass procedures performed between July 2007 and January 2014. RESULTS: 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. CONCLUSION: 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.