Facing a Feared Situation: Endoscopic Endonasal Approach for Petroclival Lesions With Internal Carotid Artery Encasement: 2-Dimensional Operative Video

2020 ◽  
Author(s):  
Yury Anania ◽  
Andrew S Venteicher ◽  
Eric W Wang ◽  
George A Zenonos ◽  
Carl H Snyderman ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Single Photon ◽  
Photon Emission ◽  
Complete Removal ◽  
Emission Computed Tomography ◽  
Endoscopic Endonasal ◽  
Cavernous Sinus Invasion ◽  
Cranial Nerve Palsies

Abstract A 33-yr-old woman presented with diplopia due to partial III and VI cranial nerve palsies, and an magnetic resonance imaging (MRI) showed a left petroclival lesion with cavernous sinus invasion. The ipsilateral internal carotid artery (ICA) was displaced and encased by the tumor. Chondroid tumors such as this are known to be high risk for ICA injury1; however, given the patient's young age a radical resection was desirable,2 depending on the risk of such a strategy. Therefore, a preoperative balloon test occlusion (BTO) was performed to estimate the risk of stroke in case of ICA sacrifice.3 Clinical and single-photon emission computed tomography testing predicted low risk of stroke, allowing for aggressive resection. A preoperative ICA occlusion was not performed as intraoperative control was believed to be adequate and preservation is always preferable when possible due to rare inaccuracies in BTO and long term risks of occlusion. An endoscopic endonasal and right contralateral transmaxillary approach with intraoperative neurophysiology were performed to remove this lesion.4,5 During surgery, the ICA proved dehiscent, and was therefore clip sacrificed.6 An immediate postoperative digital subtraction angiography showed minimally delayed, but adequate, blood flow to the left cerebral hemisphere. Postoperative MRI showed complete removal and no significant infarct. The patient was discharged in stable neurological condition, with only a slightly worsened CN III palsy. Experience with management of ICA injury is of uttermost importance in endoscopic endonasal surgery,1,2 and requires adequate training and an experienced 2-surgeon team.7 The patient provided consent to the submission and publication of the related surgical video.

Endovascular recanalization of the completely occluded internal carotid artery using a flow reversal system at the subacute to chronic stage

2010 ◽  
Vol 112 (3) ◽  
pp. 563-571 ◽  
Author(s):  
Tomoaki Terada ◽  
Hideo Okada ◽  
Masataka Nanto ◽  
Aki Shintani ◽  
Ryo Yoshimura ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Single Photon ◽  
Photon Emission ◽  
Emission Computed Tomography ◽  
Chronic Stage ◽  
Embolic Protection ◽  
Hemodynamic Compromise ◽  
Endovascular Recanalization

Object The efficacy and pitfalls of endovascular recanalization were evaluated in cases of internal carotid artery (ICA) occlusion in the subacute to chronic stage. Methods Fourteen cases (15 lesions) of symptomatic ICA occlusion with hemodynamic compromise or recurrent symptoms were treated at the subacute to chronic stage using an endovascular technique. The Parodi embolic protection system was used during the recanalization procedure to prevent embolic stroke by reversing the flow from the distal ICA to the common carotid artery. Results Recanalization of the occluded ICA was possible in 14 of 15 lesions. The occlusion points were 10 cervical ICAs and 4 petrous/cavernous ICAs in successfully recanalized cases. Ischemic symptoms disappeared completely after the treatment, and new ischemic symptoms did not appear related to the treated lesion. Single photon emission computed tomography findings demonstrated the improvement of hemodynamic compromise in all cases. One case showed right middle cerebral artery branch occlusion during the procedure, but this patient's neurological symptoms were stable due to preexisting hemiparesis. Endovascular recanalization was possible and effective in improving hemodynamic compromise. However, there are still several problems with this technique, such as hyperperfusion syndrome after recanalization, cerebral embolism during treatment, durability after treatment, and identification of the occlusion point before treatment. Conclusions Endovascular recanalization using an embolic protection device can be considered as an alternative treatment for symptomatic ICA occlusion with hemodynamic compromise or refractoriness to antiplatelet therapy, even in the subacute to chronic stage of the illness.

scholarly journals Endoscopic endonasal control of the paraclival internal carotid artery by Fogarty balloon catheter inflation: an anatomical study

2017 ◽  
Vol 126 (3) ◽  
pp. 872-879
Author(s):  
Andrea Ruggeri ◽  
Joaquim Enseñat ◽  
Alberto Prats-Galino ◽  
Antonio Lopez-Rueda ◽  
Joan Berenguer ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Balloon Catheter ◽  
Anatomical Study ◽  
Endoscopic Endonasal ◽  
Cavernous Sinus Invasion ◽  
Neoplastic Lesions ◽  
Temporary Occlusion ◽  
Safe Approach

OBJECTIVE Neurosurgical management of many vascular and neoplastic lesions necessitates control of the internal carotid artery (ICA). The aim of this study was to investigate the feasibility of achieving control of the ICA through the endoscopic endonasal approach by temporary occlusion with a Fogarty balloon catheter. METHODS Ten endoscopic endonasal paraseptal approaches were performed on cadaveric specimens. A Fogarty balloon catheter was inserted through a sellar bony opening and pushed laterally and posteriorly extraarterially along the paraclival carotid artery. The balloon was then inflated, thus achieving temporary occlusion of the vessel. The position of the catheter was confirmed with CT scans, and occlusion of the ICA was demonstrated with angiography. The technique was performed in 2 surgical cases of pituitary macroadenoma with cavernous sinus invasion. RESULTS Positioning the Fogarty balloon catheter at the level of the paraclival ICA was achieved in all cadaveric dissections and surgical cases through a minimally invasive, quick, and safe approach. Inflation of the Fogarty balloon caused interruption of blood flow in 100% of cases. CONCLUSIONS Temporary occlusion of the paraclival ICA performed through the endoscopic endonasal route with the aid of a Fogarty balloon catheter may be another maneuver for dealing with intraoperative ICA control. Further clinical studies are required to prove the efficacy of this method.

Use of an embolic protection system during endovascular recanalization of a totally occluded cervical internal carotid artery at the chronic stage

2005 ◽  
Vol 102 (3) ◽  
pp. 558-564 ◽  
Author(s):  
Tomoaki Terada ◽  
Hiroo Yamaga ◽  
Tomoyuki Tsumoto ◽  
Osamu Masuo ◽  
Toru Itakura
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Single Photon ◽  
Photon Emission ◽  
Protection System ◽  
Chronic Stage ◽  
Embolic Protection ◽  
Hemodynamic Compromise ◽  
Endovascular Recanalization

✓ A symptomatic internal carotid artery (ICA) occlusion with hemodynamic compromise was treated at its chronic stage by using an endovascular technique. An embolic protection system was used during the recanalization procedure to prevent stroke by reversing the flow from the distal ICA to the common carotid artery. The totally occluded ICA was completely recanalized through percutaneous transluminal angioplasty and stent placement. The patient's symptom (transient ischemic attack) disappeared completely after treatment with no new neurological deficit. Single-photon emission computerized tomography findings confirmed improvement of the hemodynamic compromise, and no new high-intensity spots appeared on diffusion-weighted magnetic resonance imaging after treatment. This case shows that endovascular recanalization by using an embolic protection device can be considered as an alternative treatment for symptomatic ICA occlusion with hemodynamic compromise and refractoriness to antiplatelet therapy, even in the chronic stage of the illness.

scholarly journals Reversal of severe SPECT asymmetry after venous extra-intracranial high flow bypass in a patient submitted to therapeutic internal carotid occlusion: case report

2001 ◽  
Vol 59 (3B) ◽  
pp. 797-801 ◽  
Author(s):  
Jorge Marcondes ◽  
Antônio Aversa ◽  
Marcio Peçanha ◽  
Flávio Domingues ◽  
Fernanda Nascimento ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Single Photon ◽  
Photon Emission ◽  
High Flow ◽  
Carotid Occlusion ◽  
Balloon Test Occlusion ◽  
Vein Bypass ◽  
Therapeutic Occlusion

Therapeutic occlusion of the internal carotid artery is the main option for the treatment of the symptomatic intracavernous internal carotid artery aneurysms, but the issue of the best way of doing the balloon test occlusion (BTO) regarding prediction of future ischemic events remains debatable. Single photon emission computerized tomography (SPECT) has been offered as one of the best option of monitoring regional cerebral blood flow (rCBF) during the BTO, where severe asymmetry is predictive of delayed ischemia. We describe a case of important SPECT asymmetry during BTO clinically negative and its complete reversal with carotid occlusion after extra-intracranial bypass with high flow safenous vein bypass between the cervical carotid artery and the middle cerebral artery.

scholarly journals Salvage of Failed Endovascular Management of Internal Carotid Artery Injury during Endoscopic Endonasal Pituitary Surgery

2020 ◽  
Author(s):  
Chandra Veer Singh ◽  
Shraddha Jain ◽  
Sagar Gourkar ◽  
Sandeep Iratwar
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Stent Graft ◽  
Fibrin Sealant ◽  
Internal Carotid ◽  
Vastus Lateralis ◽  
Vastus Lateralis Muscle ◽  
High Morbidity ◽  
Endoscopic Endonasal ◽  
Cranial Nerve Palsies

Rupture of Internal Carotid Artery (ICA) during trans-sphenoidal surgery can have high morbidity, as it results in altered mental status, stroke or cranial nerve palsies or is fatal for the patient as well. Hereby, Authors describe a case of 23-year-old female who underwent trans-sphenoidal surgery for recurrent pituitary macroadenoma. Removal of the pituitary tumour under general anaesthesia resulted in a bleeding pseudoaneurysm. Distal access catheter across the bleeding pseudoaneurysmal segment of right ICA was made and embolisation of the bleeding pseudoaneurysmal segment was done by placing stent graft. Then check angiogram was performed, which showed that significant embolisation was not achieved. Since, stent graft was unsuccessful to control bleeding, a decision was taken to perform neck dissection to clamp and control the ICA in the neck. Part of the procedure was to harvest a part of vastus lateralis muscle (1 cm × 0.5 cm), crushing it and mixing it with alternating layers of fibrin sealant. This mixture was put over the injured site for better clotting effect. The patient tolerated the procedure well, was shifted to the Intensive Care Unit and vitals were stable thereafter. There are very few instances in published literature which describe the repair of injured ICA using muscle and fibrin sealant. The present case highlights the importance of executing urgent and innovative techniques to control bleeding ICA.

Moyamoya-like Diseases Associated with Ventricular Hemorrhages: Report of Three Cases

Neurosurgery ◽  
1985 ◽  
Vol 17 (2) ◽  
pp. 260-266 ◽  
Author(s):  
Masaharu Sato ◽  
Akitsugu Kohama ◽  
Atsuhiro Fukuda ◽  
Shigeru Tanaka ◽  
Masao Fukunaga ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Single Photon ◽  
Photon Emission ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Internal Carotid Artery Occlusion ◽  
Single Photon Emission ◽  
Cerebral Artery Occlusion

Abstract Three rare cases of moyamoya-like diseases with moyamoya type vessels caused by spontaneous internal carotid artery occlusion, spontaneous middle cerebral artery occlusion, and internal carotid artery occlusion due to cervical irradiation are presented. They resulted in ventricular hemorrhages. One patient died and two survived. Postoperatively, the collateral circulation of the survivors was evaluated by single photon emission tomography using N-isopropyl-[123I]-p-iodoamphetamine. The effectiveness of reconstructive surgery is shown, and moyamoya-like diseases that have been reported are reviewed.

Nasopharyngeal muscle patch for the management of internal carotid artery injury in endoscopic endonasal surgery

2020 ◽  
Vol 133 (5) ◽  
pp. 1382-1387 ◽  
Author(s):  
Wei-Hsin Wang ◽  
Stefan Lieber ◽  
Ming-Ying Lan ◽  
Eric W. Wang ◽  
Juan C. Fernandez-Miranda ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Skull Base Surgery ◽  
Management Technique ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Muscle Graft

OBJECTIVEInjury to the internal carotid artery (ICA) is the most critical complication of endoscopic endonasal skull base surgery. Packing with a crushed muscle graft at the injury site has been an effective management technique to control bleeding without ICA sacrifice. Obtaining the muscle graft has typically required access to another surgical site, however. To address this concern, the authors investigated the application of an endonasally harvested longus capitis muscle patch for the management of ICA injury.METHODSOne colored silicone-injected anatomical specimen was dissected to replicate the surgical access to the nasopharynx and the stepwise dissection of the longus capitis muscle in the nasopharynx. Two representative cases were selected to illustrate the application of the longus capitis muscle patch and the relevance of clinical considerations.RESULTSA suitable muscle graft from the longus capitis muscle could be easily and quickly harvested during endoscopic endonasal skull base surgery. In the illustrative cases, the longus capitis muscle patch was successfully used for secondary prevention of pseudoaneurysm formation following primary bleeding control on the site of ICA injury.CONCLUSIONSNasopharyngeal harvest of a longus capitis muscle graft is a safe and practical method to manage ICA injury during endoscopic endonasal surgery.

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