B ritish Jour nal of N eurosurger y 1999;13(2):193± 195 SH ORT RE PORT M anagem ent of penetrating injury to the petrous internal carotid artery: case report M . HARPER*, A. K . DASHFIELD ² & K . S. EL-SHU NN AR* Br J Neurosurg Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only. D epartm ents of *N eurosurger y and ² Anaesthesia, D erriford H ospital, Plymouth, D evon, U K Abstract We report the management of a penetrating foreign body injury to the neck with a length of fencing wire traversing the internal carotid artery within the petrous tem poral bone and entering the m iddle cranial fossa. Discussion points include methods of haem orrhage control, as well as ligation versus repair or bypass as the de® nitive treatment. Key words: C raniotomy, foreign body, petrous inter nal carotid arter y injur y, proxim al/distal control. Introduction Managem ent of internal carotid arterial injury is made difficult because of backbleeding from the circle of W illis, which m eans that the surgeon m ust gain both proxim al and distal control of the haem orrhage. T his is reasonably straightforward if the injury involves the proxim al portion of the artery, but an injury m ore distally, especially at the skull base presents problem s w ith ga inin g distal control. We repor t a case of penetrating injury within the skull base and discuss its m anagem ent. Case report An 18-year-old male presented to the emergency room with a length of fencing wire protruding from the left side of his neck. He reported that the wire had been thrown up by a `strim m ing’ m achine, whilst cutting grass. H e had n o past m edical histo r y and w as asym ptom atic apart from pain at the site of the entry wound. Initial exam ination revealed no neurological deficit. A length of m etal wire was seen to be protruding postero-inferior to the left pinn a (F ig. 1). Plain radiographs showed the internal portion of the w ire to extend superom edially through the carotid canal to enter the m iddle cranial fossa via the foram en lacerum (Fig. 2). T his course was con® rm ed by CT (Fig. 3). Approxim ately 2 h after adm ission, w hilst still in the em ergency room , the patient developed a sudden onset of right-sided hemiplegia with expressive aphasia F IG . 1. View of the patient supporting the length of m etal wire protruding from the left side of his neck, just below and posterior to the ear. Note that the patient holds the external portion of the wire with his right hand prior to the sudden onset of a dense right-sided hem iplegia. and w as transferred urgen tly to our un it, w here cerebral angiography revealed pen etration of the petrous internal carotid artery within the carotid canal (Figs 4± 6). Anterograde ¯ ow was severely lim ited with no signi® cant ¯ ow in the middle cerebral artery. At this tim e, exam ination revealed a dense right hem iparesis with m inim al m ovem ent of the foot only. T he patient was expressively aphasic with a right central facial palsy. Surgical rem oval of the wire was undertaken by Correspondence to: M . H arper, Departm ent of Neurosurgery, Derriford Hospital, Plymouth, Devon PL6 8D H, U K. Received for publication 13th January 1998. Accepted 9th February 1998. 0268± 8697/99/020193 ± 03 $9.50 ½ T he Neurosurgical Foundation Br J Neurosurg Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only. 194 M . Harper et al. m iddle fossa and the internal carotid artery was ligated at its origin. Bleeding continued, however, and a standard cerebral aneurysm clip was applied across its supraclinoid portion. N o further bleeding occurred and the patient rem ained stable throughout the intraoperative period w ith m inim al blood loss. N o fur ther neurological deterioration was noted in the im m ediate postoperative period. At 1 week, the patient had a m oderate and im proving expressive dysphasia. He was hem iparetic with power of 4/5 (H RC grading) on the right except for the deltoid and biceps, which rem ained 1/5. He was eating and drinking, and able to m obilize with the aid of nursing staff. Repeat CT showed a sm all basal ganglia infarct with no evidence of intracranial infection or haem atom a. Broad-spectrum antibiotics were continued for 2 weeks and a 6-m onth course of aspirin com m enced. He was referred for a programm e of intensive physiotherapy and rehabilitation. At 6 weeks postoperatively the patient was walking independently with m inimal dysphas ia and im proving weakness of the right arm . F IG . 2. Plain radiographic ® lms showed the internal portion of the wire to extend superomedially through the carotid canal and to enter the middle cranial fossa. F IG . 3. On CT, the piece of wire is seen entering the middle cranial fossa through the foram en lacerum. both cervical dissection, to exp ose the origin of the internal carotid, as well as sim ultaneous pterional craniotomy to expose its supraclinoid portion, thereby gaining control both proxim ally and distally to the point of perforation by the w ire. U pon extraction of the w ire brisk bleeding occurred from the ¯ oor of the D iscussion The main principle in the m anagem ent of any internal carotid ar tery injury is to gain proxim al and distal control over the bleeding vessel, to prevent backbleeding from the circle of W illis. D istal control is m ade particularly difficult when the injur y occurs near or within the skull base. In m anag ing this case, two m ain questions needed to be addressed: which was the m ost appropriate method of distal control and should arterial repair or bypass be attem pted? Various m ethods of exposure of the internal carotid at or near the skull base have been described, 1 ± 5 however, m ost are com plicated and tim e consum ing. W hether or not to repair or bypass the affected vessel is controversial w ith m ixed postoperative outcom es reported. It is widely accepted that revascularization in patients with preoperative com a is rarely indicated owing to the high incidence of severe reperfusion injury. M ixed results have been achieved with deficits short of com a, 6 ,7 and excellent results with no or m inor neurological im pairm ent. 8 ± 1 4 In the neurologically intact patient, tem porar y balloon occlu sion testing, if available at the tim e of arteriography, m ay be of use in determ ining whether revascularization is 1 5 ,1 6 necessar y before ligation. Also, in som e centres, perm anent proxim al and distal balloon occlusion m ay be an option, but the presence of a translum inal foreign body would probably preclude this. In our patient w ith aphasia and a dense hem iparesis d ue to an in trapetrou s foreign bo dy, w e considered that ligation of the cervical ICA and craniotomy for occlusion of the supraclinoid IC A was the m ost appropriate course of action. T his is because of the ease of exp osure of the cervical ICA by standard carotid endarterectomy exposure, and also of the supraclinoid IC A as in standard aneur ysm surgery. Br J Neurosurg Downloaded from informahealthcare.com by UB Wuerzburg on 10/29/14 For personal use only. Petrous carotid injur y 195 F IG . 4± 6. Carotid arteriogram revealed that the left internal carotid artery was trans® xed by the length of wire when viewed from three different projections. These views show the wire entering the carotid canal and traversing the left internal carotid artery. It exits the superior surface of the intrapetrous carotid, the tip lying outside of the petrous bone in the lower tem poral lobe. There is no contrast leak from either the entrance or exit punctures of the vessel. Anterograde ¯ ow in the left internal carotid is very lim ited beyond the cavernous portion. Only ghost ® lling of the anterior cerebral complex is seen and no worthwhile ¯ ow is seen in the m iddle cerebral artery at all. T he fact that the wire extended intracranially m ade this method of distal control all the m ore appropriate. Because of the difficulty of exposing the petrous ICA with a foreign body in situ, it was considered that direct repair would be excessively com plicated. Arterial bypass would have been feasible, but we were concerned about the risk of reperfusion injury. O ur intention was to m inim ize operative com plications an d the tim e u n d er an aesthesia . A satisf a cto r y outcom e w as achieved with m arked neurological im provem ent after the initial postoperative period. A n giog raphy is im por tan t in any patient w ith suspected internal carotid injury, as clinical signs m ay 17 be m isleading. M cCormack and Burch found that 42% of patients thought to have arterial injur y on clinical evaluation had norm al arteriogram s and that 20% of patients thought to be free of arterial injury showed ar terial d am age on angiography. D elayed onset of cerebral sym ptom s is comm on 1 8 and our patient showed no neurological de® cit until 2 h after initial assessm ent. Arteriography allow s planning for vascular repair, bypass or ligation. References 1 Fisch U, Pillsbury HC. Infratem poral fossa approach to lesions in the tem poral bone and base of the skull. A rch Otolar yngol 1979;10 5:99± 108. 2 Glassock M E, Smith PG, Bond AG, et al. 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