Carotid Hemorrhage during Skull Base Surgery: Review of the Literature, Meta-Analysis, and Recommendations

Objectives: This study aims to perform a comprehensive literature review of the incidence, treatment, and outcome of carotid artery injury during skull base surgery, perform a meta-analysis, and determine recommendations for treatment.

Materials and Methods: Medline and Google search of the medical literature for the past 25 years of papers in English with the key words carotid, hemorrhage, skull base, otologic, rhinologic, injury, skull base, and complications.

Results: Meta-analysis of this study revealed that carotid hemorrhage is a rare, dreaded complication of skull base surgery. Various treatment modalities presented included anterior–posterior nasal packing, muscle grafts, detachable balloons, and interventional radiology to diagnose and occlude bleeding.

Conclusion: Carotid hemorrhage demands rapid, decisive action by the skull base surgical team. Rapid, aggressive anterior–posterior packing of the nasopharynx, transfusion if necessary, and prompt transfer to interventional radiology to determine the extent of bleeding is urged in these cases, which are often fatal regardless of treatment. Muscle grafts are effective but risk total occlusion of the artery with the risk of morbidity/mortality. Adequate cross-circulation, that is, intact Circle of Willis is necessary to avoid morbidity/mortality if coil occlusion of the bleeding artery is attempted. Thus, balloon occlusion testing is very useful in this regard. Skull base surgeons should practice emergency maneuvers in the cadaver or animal laboratory to be prepared for this complication.