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

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.

Delayed pseudoaneurysm formation of the carotid artery following the oral cavity injury in a child:A case report

BACKGROUND An impalement injury of the oral cavity is a common traumatic injury in children.In most cases,it is not accompanied by sequelae,but if foreign body residues are not found due to a minor injury,they may result in inflammatory responses and delayed vascular injuries in the surrounding tissues.Without early diagnosis and appropriate initial management,residual foreign bodies can cause serious complications and even mortality in some cases.CASE SUMMARY A 9-year-old boy suffered an intra-oral injury by a wooden chopstick,and the patient was discharged from the hospital after receiving conservative treatment for the injury.However,the patient was readmitted to the hospital due to intraoral bleeding,and since neck hematoma and right internal carotid artery pseudoaneurysm formation were detected on computed tomography,emergency surgery was performed.A remnant fragment of a wooden chopstick was found during the operation,and a delayed rupture of the internal carotid artery caused by the foreign body was also found.CONCLUSION The failure of early detection and diagnosis of a residual foreign body may result in delayed vascular rupture.

Spontaneous internal carotid artery pseudoaneurysm complicated with ischemic stroke in a young man:A case report and review of literature

BACKGROUND Carotid artery pseudoaneurysm(PSA)is infrequently encountered in clinical settings.Internal carotid artery(ICA)PSA complicated with ischemic stroke is rare.PSAs are typically caused by iatrogenic injury,trauma,or infection.The underlying mechanisms of spontaneous PSA formation are not well characterized.We report a healthy young man who presented with stroke as a complication of spontaneous PSA of the left ICA.CASE SUMMARY A 30-year-old man working as a ceiling decoration worker was hospitalized due to sudden-onset speech disorder and right lower extremity weakness.Medical history was unremarkable.Brain computed tomography revealed ischemic stroke.Digital subtraction angiography showed a left ICA PSA with mild stenosis.The patient was conservatively managed with oral anticoagulation and antiplatelet therapy.He recovered well and was discharged.The patient was in good condition during follow-up.CONCLUSION The occupational history of patient should be taken into consideration while evaluating the etiology of spontaneous ICA PSA in young people with stroke.

Penetrating neck injury： Collaterals for another life after ligation of common carotid artery and subclavian artery

Neck, being not protected by skeleton, is vulnerable to external trauma and injury which involves blood vessels, trachea, esophagus and other endocrine and nervous system organs. Vascular injuries can not only cause potentially, life-threatening hemorrhage but also need profound surgical expertise in man- agement. Development of collateral circulation in neck is well known： however, there is scarcity of literature on the role of collateral formation in neck trauma. Here, we present a unique case of pene- trating gunshot injury to neck with right common carotid and right subclavian artery injury with hemorrhagic shock managed with ligation of these vessels as a life-saving procedure. The patient pre- sented ~ith no neurological or motor de~,cits in immediate postoperative period owing to the collateral circulation between right vertebral artery and right common carotid and right subclavian artery.

A Preliminary Study of the Therapeutic Role of Human Early Fetal Aorta-derived Endothelial Progenitor Cells in Inhibiting Carotid Artery Neointimal Hyperplasia

Background： Endothelial cell damage is an important pathophysiological step of restenosis after angioplasty and stenting. Cell transplantation has great therapeutic potential for endothelial recovery. We investigated the effect of transplanting endothelial progenitor cells （EPCs） derived from human early fetal aortas in rat injured arteries. Methods： The carotid arterial endothelium of Sprague-Dawley rats was damaged by dilatation with a 1.5 F balloon catheter, and then EPCs derived from human early fetal aortas （〈14 weeks） were injected into the lumen of the injured artery in transplanted rats, with an equal volume of normal saline injected into control rats. Rats were sacrificed at 2 and 4 weeks after treatment and transplanted cells were identified by immunohistochemical staining with anti-human CD31 and anti-human mitochondria antibodies. Arterial cross-sections were analyzed by pathology, immunohistochemistry, and morphometry. Results： Green fluorescence-labeled EPCs could be seen in the endovascular surface of balloon-injured vessels after transplantation. The intimal area and intimal/medial area ratio were significantly smaller in the transplanted group than in the control （P 〈 0.05） and the residual lumen area was larger （P 〈 0.05）. After EPC transplantation, a complete vascular endothelial layer was formed, which was positive for human yon Willebrand factor after immunohistochemical staining, and immunohistochemical staining revealed many CD31- and mitochondria-positive cells in the re-endothelialized endothelium with EPC transplantation but not control treatment. Conclusion： EPCs derived from human early fetal aorta were successfully transplanted into injured vessels and might inhibit neointimal hyperplasia after vascular injury.

Surgical treatment for traumatic transection of left common carotid artery

Injury to the supraaortic artery is a rare event, with poor prognosis and high mortality.1 Improvement of the outcome may lie on the combination of several aspects, including better pre-hospital care, use of emergency cardiopulmonary bypass （CPB）, improved surgical techniques and facilities, and advanced postoperative intensive care. Some researchers emphasized the importance of emergency CPB in the treatment and thought that it was responsible mainly for the improved outcome.2-6 However, there exists controversies about it.7-9 In this article, we reported that a patient with life-threatening hemorrhage due to traumatic transection of the left common carotid artery, who was admitted to our hospital in July 2003, was treated successfully with operations with help of emergency CPB and systemic hypothermia.