Internal carotid artery injury during endoscopic endonasal surgery for skull base pathologies: an institutional incidence, management, and outcome.

BACKGROUND: Endoscopic endonasal surgery (EES) has become a popular approach to deal with skull base pathologies. The most catastrophic intra-operative complication of EES is internal carotid artery (ICA) injury. We aim to discuss and introduce our institutional experience with ICA injury during EES. METHODS: A retrospective review of patients who underwent EES from 2013 to 2022 was performed to determine the incidence and outcomes of intraoperative ICA injuries. RESULTS: There were six patients (0.56%) with intraoperative ICA injury in our institution during the last 10 years. Fortunately, there was no morbidity or mortality in our patients with intraoperative ICA injuries. The sites of injury were equally in paraclival, cavernous sinus, and preclinoidal segments of ICA. CONCLUSION: Primary prevention is the best solution for this condition. Regarding our institutional experience, the best option for primary management just after an injury is packing the surgical site. In cases where packing is not enough for temporary control of bleeding, common carotid artery occlusion should be considered. We have presented our experience and reviewed previous studies regarding different treatments and suggested our intra and post-operative management algorithm.

Blunt Traumatic Vertebral Artery Injuries: Incidence, Therapeutic Management, and Outcomes.

BACKGROUND: Blunt cerebrovascular injury (BCVI) is a term for injuries to the carotid and vertebral arteries (blunt vertebral artery injury [BVAI]) caused by blunt trauma. Computed tomographic angiography is currently the best screening test for BCVI. The subsequent management of any identified vessel injury, however, is not clearly defined. OBJECTIVE: To describe one of the largest cohorts of isolated vertebral artery injuries and report the evolution of treated and untreated lesions and clinical outcomes of treatment regimens used to reduce the risk of injury-related stroke. METHODS: The list included patients who presented to or were transferred to a level 1 trauma center and found to have an isolated BVAI. Patients were included if imaging was performed within 24 hours of presentation. Data collected included location and grade of injury, timing and type of initial therapy, follow-up imaging, evolution of the disease, and associated strokes. RESULTS: A total of 156 patients were included in the analysis. Most patients (135/156) were treated with aspirin alone, 3 with anticoagulation therapy, and 18 did not receive treatment. Three strokes were detected within 24 hours of admission and before treatment initiation. No strokes were detected during the length of the hospitalization for any other patient. CONCLUSION: Our data demonstrate that the risk of stroke after cervical vertebral artery injury is low, and aspirin as a prophylactic is efficacious in grade I and IV injuries. There are limited data regarding grade II and grade III injuries. The benefit of early interval imaging follow-up is unclear and warrants investigation.

Recurrent Rathke's Cleft Cysts: Incidence and Surgical Management in a Tertiary Pituitary Center over 2 Decades.

BACKGROUND: Limited data exist pertaining to outcomes following surgery for recurrent Rathke's cleft cysts (RCC). OBJECTIVE: To determine treatment outcomes in patients undergoing reoperation for recurrent or residual RCCs. METHODS: A retrospective analysis of 112 consecutive RCC operations in 109 patients between 1995 and 2017 was conducted. RESULTS: Eighteen patients underwent 21 RCC reoperations with a mean follow-up of 58 mo. Patient symptoms prior to reoperation included headaches (14, 66.7%) and vision loss (12, 57.1%). Thirteen of 18 patients (72.2%) required hormone supplementation prior to reoperation including 5 with diabetes insipidus (DI). Mean RCC diameter was 16 mm and 76% had suprasellar extension. Compared to index RCC cases, intraoperative cerebrospinal fluid leak repair was more common in reoperation cases (15/21, 71% vs 43/91, 47%, P = .05). There was 1 carotid artery injury without neurological sequelae, and 2 postoperative cerebrospinal fluid (CSF) leaks (9.5%). Rates of transient hyponatremia (3/10, 30% vs 4/91, 4.4%, P = .04) and transient DI (5/10, 50% vs 17/91, 18.7%, P = .04) were higher in the reoperation vs index group. Improved headaches and vision were reported in 4/12 (33%) and 8/12 (61.5%) of RCC reoperation patients, respectively. Two patients developed new permanent DI. A higher proportion of reoperation patients had RCC squamous metaplasia (24% vs 5.4%, P = .02) or wall inflammation (42.9% vs 2.2%, P < .001) on pathological examination. CONCLUSION: Reoperation for RCCs is generally safe at tertiary pituitary centers and often results in improved vision. Hypopituitarism is less likely to improve following reoperation for recurrent RCCs. Several histopathological features may help characterize "atypical RCCs" with a higher likelihood of recurrence/progression.

Carotid artery dissection and motor vehicle trauma: patient demographics, associated injuries and impact of treatment on cost and length of stay.

BACKGROUND: Blunt carotid arterial injury (BCI) is a rare injury associated with motor vehicle collision (MVC). There are few population based analyses evaluating carotid injury associated with blunt trauma and their associated injuries as well as outcomes. METHODS: The Nationwide Inpatient Sample (NIS) 2003-2010 data was queried to identify patients after MVC who had documented BCI during their hospitalizations utilizing ICD-9-CM codes. Demographics, associated injuries, interventions performed, length of stay, and cost were evaluated. RESULTS: 1,686,867 patients were estimated having sustained MVC; 1,168 BCI were estimated. No patients with BCI had open repair, 4.24 % had a carotid artery stent (CAS), and 95.76 % of patients had no operative intervention. Age groups associated with BCI were: 18-24 (27.8 %), 47-60 (22.3 %), 35-46 (20.6 %), 25-34 (19.1 %), >61 (10.2 %). Associated injuries included long bone fractures (28.5 %), stroke and intracranial hemorrhage (28.5 %), cranial injuries (25.6 %), thoracic injuries (23.6 %), cervical fractures (21.8 %), facial fractures (19.9 %), skull fractures (18.8 %), pelvic fractures (18.5 %), hepatic (13.3 %) and splenic (9.2 %) injuries. Complications included respiratory (44.2 %), bleeding (16.1 %), urinary tract infections (8.9 %), and sepsis (4.9 %). Overall mortality was 14.1 % without differences with regard to intervention (18.5 % vs. 13.9 %; P = 0.36). Stroke and intracranial hemorrhage was associated with a 2.7 times greater risk of mortality. Mean length of stay for patients with BCI undergoing stenting compared to no intervention were similar (13.1 days vs. 15.9 days) but had a greater mean cost ($83,030 vs. $63,200, p = 0.3). CONCLUSION: BCI is a rare injury associated with MVC, most frequently reported in younger patients. Frequently associated injuries were long bone fractures, stroke and intracranial hemorrhage, thoracic injuries, and pelvic fractures which are likely associated with the force/mechanism of injury. The majority of patients were treated without intervention, but when CAS was utilized, it did not impact mortality and trended toward increased costs.