Catastrophic Bleeding in Endoscopic Endonasal Surgery: Prevention and Management Protocol

Objectives: (1) To analyze the risk factors that could lead to internal carotid artery (ICA) injury during endoscopic endonasal surgery. (2) To implement a cascade protocol in perioperative management of ICA injury. Methods: A multicentric case series analysis along with literature review that has been conducted in December, 2013 for the cases that encountered ICA injury during endoscopic endonasal surgery. The risk factors and the main preoperative, intraoperative, and postoperative measures have been described. Results: Resection of a lesion that is adherent to the carotid with curative intent, exposure of more than one segment of ICA and encirclement of ICA >1,200 are considered a high risk factors along with other relative risk factors. The stated protocol involves the main preoperative analytic and diagnostic workup, intraoperative formulated plan of actions along with standards postoperative follow-up measurements. Conclusion: Internal carotid artery injury is the most dramatic complications of endoscopic endonasal surgery. The incidence increases in complex cases that involve skull base. Identifying patients at risk is crucial in the management. Intraoperative preparation and well instrumentations minimize the devastating sequelae. Multidisciplinary team approach is overemphasized throughout the management protocol.