Sphenoid Wall Dehiscence: A Preventable Cause
of Iatrogenic Internal Carotid Artery Rupture
Prashant Punia*1, Ashish Chugh1, Sarang Gotecha1 and Vinod Shinde2
1Department of Neurosurgery, Dr DY Patil Medical College and Hospital, India
2Department of Otorhinolaryngol, Dr D Y Patil medical College, India
Submission: September 22, 2020;Published: October 09, 2020
*Corresponding author: Prashant Punia, Department of Neurosurgery, Dr. DY Patil Medical College, Hospital and Research Center, Sant Tukaram Nagar, Pimpri, Pune
How to cite this article: Prashant Punia, Ashish Chugh, Sarang Gotecha,Vinod Shinde. The Role of Metallothionein-3 in Brain Diseases. Open Access J Neurol Neurosurg 2020; 14(2): 555885. 10.19080/OAJNN.2020.14.555885.
Keywords: Extradural hematoma; EDH; Remote EDH
• All sources of financial and material support including the following: NA
• Any portion of the contents of the paper may have not been presented or published previously.
Dehiscent Internal Carotid Artery in Pituitary Tumor Surgery: Early Recognition and Avoidance of
Minimally Invasive approaches to pituitary tumor have become gold standard not just for pituitary surgery but also for pathologies of ventral skull base . It is due to the fantastic view it offers and the ease of doing surgery. The same, however, are not without complications and rupture of Internal Carotid Artery (ICA) is potentially the most catastrophic and thus, most feared . ICA is unique in presenting the number of curvatures intracranial, especially through its passage out of carotid canal and along the side of sphenoid bone where its form resembles the English alphabet S.The incidence of ICA rupture in trans sphenoidal surgeries is 1.1%  and is limited to a few case reports. There is hardly any standard protocol available for the management of the same and considering the ever increasing applicability and use of Trans sphenoidal surgery, this incidence is expected to rise. Authors have reviewed various articles on the same and present salient pre and intraoperative checkpoints for early identification of ICA rupture due to sphenoid bone dehiscence and in turn avoidance of this disastrous complication.
Adequate knowledge and thorough understanding of the relevant anatomy of not just sella but also nasal cavity, sinuses and parasellar structures is a must, especially through an endoscopic perspective. This may be done via a small preoperative clinical examination followed by an endoscopic survey in the outpatient department if deemed necessary. At the level of nasal cavity, any evident Deviated Nasal septum (DNS) or turbinate hypertrophy
must be noted and accounted for. This might prove crucial in planning the access to the lesion and thus the ICA in case of inadvertent rupture. Studious assessment of preoperative Computed Tomography (CT) scan of brain and paranasal sinuses cannot be overstressed as the extent of pneumatisation of sphenoid sinus must be noted along with the position of its septum. This is crucial as it not only directs the access but also provides information about the relationship of cavernous ICA and lateral sphenoid wall. At the same time, it provides a fair clue to the distance between the two ICA’s. Fuji et al. stated that in 88% of the patients, the thickness of bony wall overlying the ICA is less than 5mm and thus it forms a very thin barrier and must be kept in mind during sphenoid sinus bone removal which must be done with utmost care. Further 4-20% patients have a dehiscent bony wall wherein the ICA is separated from sphenoid sinus only by dura and mucosa. This makes them theoretically vulnerable to iatrogenic injuries with the possibility of uncontrollable and life threatening hemorrhages. This makes a CT scan absolutely mandatory prior to any endonasal surgery and also worth noting is that axial sections provide more information about ICA than coronal or sagittal sections . Figure 1.
In the sphenoid sinus, it has been demonstrated that the ICA can be located close to the lateral wall in about 70% of the patients [7-9].and thus careful manipulation is required not only while removing the sphenois sinus bone but also the sinus mucosa overlying ICA. This becomes even more significant when
bony dehiscence is noted. Visible pulsations of the ICA provide yet
another clue to the possible dehiscence of ICA and should warn
the surgeon against extensive and aggressive maneuvers in the
vicinity. Intraoperative preparedness is not limited to prevention
but also management of this mega event as the paucity of time
and urgent nature of this event may cloud the judgment of the
best of surgeons. Various management options include but not
limited to packing, direct repair whenever possible, muscle patch
and an endovascular repair. Gauge is the most commonly used
material for packing8 and although readily available, should be
kept at hand always. Also, sites for harvesting a muscle patch
should be prepared, scrubbed and ready in case of an urgent
need of a free muscle patch. These patches have been proved to
be more effective than oxidized cellulose in experimental models9
and may be harvested from quadriceps or sternocleidomastoid
muscle. A multidisciplinary approach is needed in such testing
times and while teaming with the radiologist provides an
excellent information preoperatively, an endovascular team
should always be intimated prior to be readily available in case
of such a complication. To conclude, ICA rupture during pituitary
surgery is a disastrous complication carrying a high mortality of
22-28% and although rare, isn’t totally unheard of. Steep learning
curve and a 2D anatomy view provided by endoscopes require
precise hand eye coordination and dexterity which is a must and
surgeons should be trained on modules before getting a hands on
experience. Absolute avoidance of this complication isn’t possible
due to ever present anatomical variations and thus mental
preparedness, high index of suspicion and early recognition are
the mainstays for determining the ease of surgery and avoidance
of this potential pitfall. Prevention is the best treatment for
every iatrogenic injury and the integration of knowledge with
experience can result in futher reduction in rates of the same.
Being forewarned is being forearmed.