Emergency treatment and anesthesia management of internal carotid artery injury during neurosurgery: Four case reports

Abstract

BACKGROUND

During skull base surgery, intraoperative internal carotid artery (ICA) injury is a catastrophic complication that can lead to fatal blood loss or secondary cerebral ischemia. Appropriate management of ICA injury plays a crucial role in the prognosis of patients. Neurosurgeons have reported multiple techniques and management strategies; however, the literature on managing this complication from the anesthesiologist’s perspective is limited, especially in the aspect of circulation management and airway management when patients need transit for further endovascular treatment.

CASE SUMMARY

We describe 4 cases of ICA injury during neurosurgery; there were 3 cases of pathologically proven pituitary adenoma and 1 case of cavernous sinus endothelial meningioma. After the onset of ICA injury, all four patients were immediately transferred for endovascular therapy under general anesthesia with vital signs monitored and mechanical ventilation. Three patients were transferred to the hybrid operating room, and one patient was transferred to the catheter operating room. Three patients underwent covered stent implantation, and one patient underwent embolization. All four patients experienced hypovolemic shock and received blood products infusion and vasoactive drugs to maintain stable circulation. After the neurosurgery, one patient was extubated and returned to the ward, and the other three were delayed tracheal extubation and returned to the intensive care unit. One patient died from serious neurological complications after 62 d in the hospital, but the other three showed good clinical outcomes.

CONCLUSION

ICA injury imposes a high risk of massive hemorrhage and subsequent infarction. Immediate treatment is critical and requires interdisciplinary collaboration among neurosurgeons, anesthesiologists, and interventional neuroradiologists. Effective hemostatic methods, stable hemodynamics sufficient to ensure perfusion of vital organs, airway safety during transit, rapid localization and implementation of appropriate measures to occlude the damaged vessel are strong guarantees of patient safety.

Keywords: Complication; Internal carotid artery injury; Neurosurgery; Anesthesia Management; Literature review; Case reports

Core Tip: Intraoperative internal carotid artery (ICA) injury is an uncommon but life-threatening event that usually requires transfer to a hybrid or catheter operating room for urgent endovascular treatment; however, the literature on the management of this complication from the anesthesiologist’s perspective is limited. This case series documents four cases of ICA injury during skull base neurosurgery. Effective hemostatic procedures, hemodynamic stabilization and maintenance of mechanical ventilation during and after transfer, rapid localization and implementation of necessary measures to occlude the injured vessel are solid guarantees of patient safety.