Major Cerebral Artery Injury during Skull Base Meningioma Resection: Critical Video Analysis of Institutional Experience and Systematic Review of Literature

Introduction: Skull base meningiomas (SBM) often encompass major intracranial vessels. Injury to these vessels during surgical resection is rare; however, management of such complications is tough. The goals of our study are to (1) retrospectively evaluate the incidence and outcomes of major vessel iatrogenic injury during removal of SBM at our institution and provide critical video analysis of the complication and (2) perform a systematic review of literature to analyze the factors associated with the major vessel injury, technical pearls and outcomes.

Methods: Retrospective analysis was done for major vessel injuries (ICA, VA, and basilar artery or its major branch) during SBM resections during 2010 to August 2018 done at a U.S. academic center. We evaluated the videos for the complications and present for critical analysis. Systematic review of literature was done using standard PRISMA guidelines for data collection through EMBASE, Cochrane, PubMed, Google Scholar databases for the years 2000–2018.

Results: A total of 155 patients of SBM were operated and 3 cases were identified with major vessel iatrogenic injury (<2%). One patient died and one had poor GOS outcome, and one had good outcome. The factors identified for the injury were (1) age > 70 years, (2) injury during blunt dissection of the carotid artery, (3) bilateral encasement of the carotid/anterior communicating artery, and (4) higher grade meningioma. One of the injuries could not be repaired and in the other case carotid artery was sacrificed. Systematic review revealed that major vessel injury is reported in <  1% and major branches injury is reported in <  3% of cases. Summaries of challenging factors associated with vascular iatrogenic injury reported are (1) encasement of vessel (more common if the carotid caliber is compromised), (2) lack of arachnoid plane around the arteries, (3) older age patients with associated atherosclerosis.

Conclusion: Major cerebral artery injury in skull base meningiomas are rare but outcomes are generally poor. Even blunt dissection could be devastating if the artery wall is compromised by the tumor and patient has associated vascular pathology as determined by our critical video analysis. Partial or complete encasement of the vessel wall and lack of arachnoid plane is a high risk for vascular injury.