Endoscopic endonasal approach for the treatment of a large clival giant cell tumor complicated by an intraoperative internal carotid artery rupture

Abstract

Giant cell tumors (GCTs) are primary bone neoplasms that rarely involve the skull base. These lesions are usually locally aggressive and require complete removal, including the surrounding apparently healthy bone, to provide the best chance of cure. GCTs, as well as other lesions located in the clivus, can nowadays be treated by a minimally invasive fully endoscopic extended endonasal approach. This approach ensures a more direct route to the craniovertebral junction than other possible approaches (transfacial, extended lateral, and posterolateral approaches). The case reported is a clival GCT operated on by an extended endonasal approach that provides another contribution on how to address one of the most feared complications attributed to this approach: a massive bleed due to an internal carotid artery injury.

ICAR: endoscopic skull‐base surgery

“…Identification of the injury site may be a challenge given the constricted surgical space and the need to keep the endoscope clean to maintain adequate visualization. Multiple retrospective studies have recommended a 2‐surgeon approach because it may be beneficial to introduce an additional suction into the field, diverting blood from the endoscope and maintaining visualization . The most commonly reported ICA segment injured is the C4 (parasellar) segment; however, the C2 (petrous), C3 (paraclival), and C5 (paraclinoidal) segments have also been reported .…”

“…Once the injury site has been identified, initial control of the hemorrhage is attempted with packing and compression . Packing materials reported for initial hemostatic control include gauze, oxidized cellulose ([Surgicel™ (Ethicon, Inc.; Somerville, NJ)], cottonoids/cotton strips, Surgifoam™ (Ethicon, Inc.; Somerville, NJ), and Merocel (Medtronic Inc., Minneapolis, MN) nasal packs with balloon tamponade . The most frequently reported packing material is gauze .…”

Internal carotid artery injury in endoscopic endonasal surgery: A systematic review

“…Padhye et al and Iacoangeli et al reported the use of image guidance technology in one case each. The current literature remains controversial on the topic of intraoperative use of image guidance software and reduction in complications during EES .…”

Endoscopic Endonasal Treatment of a Large Clival Giant Cell Tumor Invading the Cavernous Sinus and Temporal Lobe

“…7,8 Complete tumor removal and drilling of the surrounding healthy bone are preferable to expect a clinical cure and to reduce recurrence rate. 9 The recommended treatment of GCTs is functionpreserving surgery. 10 After complete resection, local control is achieved in 85% to 90% of all cases, but incomplete resection is frequently associated with tumor recurrence in up to 50% of the cases.…”

“…10 Today, GCTs, as well as other lesions located in the sphenoid sinus and clivus, can be treated using an extended endoscopic endonasal approach (EEA) safely and effectively. 9 This approach gives a more direct route with better visualization to the craniovertebral junction than that of other possible approaches.…”