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Clinoidectomy and Carotid Injury

November 11, 2018


This short video reviews techniques for management of carotid artery injury during completion of extradural clinoidectomy. This is a patient who was suffering from a medial sphenoid wing meningioma with optic apparatus compression. A left-sided frontal temporal craniotomy was completed. Here's the dura over the sub frontal area, the roof of the orbit, the dura of the temporal lobe, the superior orbital fissure, and here's the medial wall of the clinoid process. The optic nerve has already been unroofed and decompressed. As you can see this procedure was primarily extradural at this stage of the operation, to decompress the optic nerve extradurally early on during the procedure. My fellow was drilling the medial wall of a clinoid. He was primarily focused on drilling the walls without paying significant attention of how much pressure was exerted on the tip of the drill and where exact location of the carotid artery would be relative to the area that he was working on. Here, you can see the thin wall of the clinoid process. He's placing more tension than needed at the tip of the drill. Arterial bleeding was encountered. At this juncture, I took over. A piece of cotton soaked and thrombin was used to tamponade the area of the bleeding, obviously primary repair of the artery is not possible in this location. This cotton was used to tamponade the bleeding for about a minute or so. Patience is required. Here, you can see it in the small piece of cotton, soaked in thrombin, placed directly on the area of the bleeding, kept in place for about a minute or so, and left permanently in there. We have had no complications by leaving small piece of cotton within our surgical area permanently. This maneuver provided hemostasis. Since the optic nerve was already decompressed, further bone removal was not pursued. Next, the dura was permanently tacked up to the edges of the pericranium and the fascia of the temporalis muscle. Number one, this excluded the area of the bleeding with the cotton in place from the intradural space. And second, it permanently tamponaded the area of the bleeding using the tension on the dura of the subfrontal area. The rest the procedure, intradural was completed. Here, you can see the optic nerve after the meningioma was removed and the nerve was decompressed. You can see the tension on the dura, and the piece of cotton that's slightly herniating through the dural opening there, but again, the area of the bleeding, which is located here, is nicely excluded. And fortunately, this patient did not suffer from any untoward complications after surgery. CT angiogram was performed immediately after surgery, which did not reveal any evidence of pseudoaneurysm, a repeat cerebral angiogram, a catheter angiogram about a week later also did not reveal any delayed formation of a pseudoaneurysm. If a pseudoaneurysm was apparent, endovascular standing procedure would be warranted. Thank you.

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