Ajlan Abdulrazag, Babateen Emad M, Alqurashi Ashwag
Division of Neurosurgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Department of Neurosurgery, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
Neurosurg Pract. 2024 Jan 11;5(1):e00073. doi: 10.1227/neuprac.0000000000000073. eCollection 2024 Mar.
Internal carotid artery (ICA) injury is a devastating complication of endoscopic endonasal surgery. We report a case of completely resected clival chordoma using endoscopic endonasal surgery despite intraoperative ICA injury. Intraoperative MRI (iMRI) was used to localize the bleeding site, confirm resection degree and ICA patency distal to the injury site, and rule out intraoperative ischemia.
A 16-year-old girl presented with right-sided facial paresthesia and was diagnosed with a large, invasive skull base lytic lesion centered in the clivus. The patient's neurological examination was normal, except for decreased sensation on the right side of the face. During tumor resection, massive bleeding occurred from the ICA paraclival segment, which was by applying direct pressure using hemostatic agents. Partial tumor resection, no clear signs of ischemic injury, and a patent flow distal to the ICA injury site were observed using iMRI. These findings helped in the decision to proceed with surgery and complete gross total resection. Postoperative angiography immediately performed after surgery revealed a pseudoaneurysm that was successfully embolized with coils. After discharge with no new neurological deficits, the postoperative imaging showed complete resection and no evidence of ischemic stroke in the injured ICA distribution.
Although not commonly used to detect skull base lesions, iMRI was valuable in our chordoma case and enabled the surgical team to proceed with a complete surgical resection. It provided real-time evaluation of the injury and possible complications. Thus, iMRI should be considered for high-risk skull base ICA injuries.
颈内动脉（ICA）损伤是鼻内镜手术的一种灾难性并发症。我们报告一例尽管术中出现ICA损伤，但仍通过鼻内镜手术完全切除斜坡脊索瘤的病例。术中磁共振成像（iMRI）用于定位出血部位、确认切除程度以及损伤部位远端ICA的通畅情况，并排除术中缺血。
一名16岁女孩出现右侧面部感觉异常，被诊断为以斜坡为中心的大型侵袭性颅底溶骨性病变。除右侧面部感觉减退外，患者的神经系统检查正常。在肿瘤切除过程中，ICA海绵窦旁段发生大量出血，通过使用止血剂直接压迫进行止血。使用iMRI观察到部分肿瘤切除，无明显缺血性损伤迹象，且ICA损伤部位远端血流通畅。这些发现有助于做出继续手术并完成肿瘤全切的决定。术后立即进行的血管造影显示有一个假性动脉瘤，成功用弹簧圈栓塞。出院时无新的神经功能缺损，术后影像学检查显示肿瘤完全切除，且在受损ICA分布区域无缺血性卒中迹象。
尽管iMRI不常用于检测颅底病变，但在我们的脊索瘤病例中它很有价值，使手术团队能够进行完整的手术切除。它提供了对损伤及可能并发症的实时评估。因此，对于高危的颅底ICA损伤应考虑使用iMRI。
