Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Sep 26, 2022; 10(27): 9865-9872
Published online Sep 26, 2022. doi: 10.12998/wjcc.v10.i27.9865
Emergency treatment and anesthesia management of internal carotid artery injury during neurosurgery: Four case reports
Jie Wang, Yu-Ming Peng
Jie Wang, Yu-Ming Peng, Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
Author contributions: Wang J contributed to data collection and reviewed the literature and manuscript drafts; Peng YM contributed to manuscript editing; and all authors have read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Yu-Ming Peng, MD, PhD, Chief Doctor, Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119 Southwest 4th Ring Road, Beijing 100070, China.
Received: May 11, 2022
Peer-review started: May 11, 2022
First decision: May 31, 2022
Revised: June 19, 2022
Accepted: August 17, 2022
Article in press: August 17, 2022
Published online: September 26, 2022

During skull base surgery, intraoperative internal carotid artery (ICA) injury is a catastrophic complication that can lead to fatal blood loss or secondary cerebral ischemia. Appropriate management of ICA injury plays a crucial role in the prognosis of patients. Neurosurgeons have reported multiple techniques and management strategies; however, the literature on managing this complication from the anesthesiologist’s perspective is limited, especially in the aspect of circulation management and airway management when patients need transit for further endovascular treatment.


We describe 4 cases of ICA injury during neurosurgery; there were 3 cases of pathologically proven pituitary adenoma and 1 case of cavernous sinus endothelial meningioma. After the onset of ICA injury, all four patients were immediately transferred for endovascular therapy under general anesthesia with vital signs monitored and mechanical ventilation. Three patients were transferred to the hybrid operating room, and one patient was transferred to the catheter operating room. Three patients underwent covered stent implantation, and one patient underwent embolization. All four patients experienced hypovolemic shock and received blood products infusion and vasoactive drugs to maintain stable circulation. After the neurosurgery, one patient was extubated and returned to the ward, and the other three were delayed tracheal extubation and returned to the intensive care unit. One patient died from serious neurological complications after 62 d in the hospital, but the other three showed good clinical outcomes.


ICA injury imposes a high risk of massive hemorrhage and subsequent infarction. Immediate treatment is critical and requires interdisciplinary collaboration among neurosurgeons, anesthesiologists, and interventional neuroradiologists. Effective hemostatic methods, stable hemodynamics sufficient to ensure perfusion of vital organs, airway safety during transit, rapid localization and implementation of appropriate measures to occlude the damaged vessel are strong guarantees of patient safety.

Keywords: Complication, Internal carotid artery injury, Neurosurgery, Anesthesia Management, Literature review, Case reports

Core Tip: Intraoperative internal carotid artery (ICA) injury is an uncommon but life-threatening event that usually requires transfer to a hybrid or catheter operating room for urgent endovascular treatment; however, the literature on the management of this complication from the anesthesiologist’s perspective is limited. This case series documents four cases of ICA injury during skull base neurosurgery. Effective hemostatic procedures, hemodynamic stabilization and maintenance of mechanical ventilation during and after transfer, rapid localization and implementation of necessary measures to occlude the injured vessel are solid guarantees of patient safety.