Carotid Iatrogenic Injury during Transsphenoidal Surgery: Aviation “Style” Reporting and Investigation

Introduction: The role of error and its relationships to human factor have been largely recognized in aviation, leading to a considerable safety improvement. A similar process is in its embryonic stage in neurosurgery.

Design: To report an intraoperative incident according to the model that is used in aviation for incident analysis.

Methods: A case of iatrogenic carotid injury during transsphenoidal endoscopic surgery is reported according to the aviation accident investigation protocol (Annex 13). The SHEL model of investigation is applied to analyze the system with a particular attention to human factor.

Results: During a transsphenoidal endoscopic approach on a 42-year-old gentleman for an invasive pituitary adenoma, the left carotid artery was injured by the debride device. Immediate massive nasal packing saved the patient's life. A 3D angio-CT revealed damage of the medial wall of the left carotid artery in its C3 segment. Perfusion-diffusion MRI ruled out ischemic brain injury. Digital angiography showed the injured artery without pseudoaneurysms or active bleeding. Ballon test occlusion disclosed delay in venous circulation that contraindicated immediate carotid occlusion. A left superficial temporal-middle cerebral artery bypass was performed before definitive carotid artery occlusion. The postoperative course was uneventful, and the patient was discharged without any new neurological deficit. Complete tumor removal was achieved in second-stage surgery 1 month later.

Conclusion: The application of an aviation style analysis to this kind of incident was found useful to draw general recommendations that may reduce the risk of carotid injury during endoscopic transsphenoidal surgery.