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.
