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American Journal of Rhinology & Allergy

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Identifying Best Practices for Managing © The Author(s) 2021
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DOI: 10.1177/19458924211024864
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Consensus of Expert Opinion

Zachary M. Kassir, BA1, Paul A. Gardner, MD2,

Eric W. Wang, MD3, Georgios A. Zenonos, MD2,
and Carl H. Snyderman, MD, MBA3

Abstract
Background: Injury to the internal carotid artery (ICA) is a potentially devastating complication of endoscopic endonasal
surgery (EES) that as many as 20% of skull base surgeons will experience at least once during their careers. Managing
these injuries is difficult given the small operative field and poor visibility created by high-flow hemorrhage, and, at present,
there is no consensus regarding best practices.
Objective: This study seeks to consolidate the practices and opinions of experienced skull base surgeons from high-volume
tertiary care centers into a single consensus statement regarding the best practices for managing ICA injuries during EES.
Methods: A panel of 23 skull base surgeons (15 neurosurgeons and 8 otolaryngologists) completed a 3-round Delphi survey
that assessed experiences and opinions regarding various aspects of ICA injury management. Mean (SD) years since fellowship
completion was 15.6 (8.1) and all but 3 surgeons had experienced an ICA injury at least once.
Results: The final consensus statement included 36 guidelines all of which were grouped under 1 of 4 categories: 11 state-
ments concerned preoperative management and equipment for high-risk patients; 14 statements concerned hemorrhage con-
trol; 4 statements concerned definitive management; 7 statements concerned pharmacologic treatment, blood pressure, and
neurophysiologic monitoring.
Conclusions: There are numerous decisions that a surgeon must make when facing a carotid artery injury. In our estimation,
many questions can be grouped under 1 of the 4 categories outlined in our consensus statement and can be addressed by
these findings.

Keywords
endoscopic skull base surgery, internal carotid artery, vascular injury, Delphi method, sinus surgery

Introduction outcomes.3 The sporadic nature of reporting and limited

Endoscopic endonasal surgery (EES) is the preferred method
for managing many neoplastic and inflammatory diseases of
the anterior skull base. Of all the possible complications of
EES, by far the most feared is iatrogenic injury to the internal
carotid artery (ICA). While potentially devastating, ICA
injury during EES is rare; among cases of endoscopic pitui-
tary surgery, the incidence is ∼1%.1 However, it is also
true that as many as 20% of skull base surgeons will experi-
ence this complication at least once during their careers.2
Management of these injuries can be extremely difficult
given the small operative field and poor visibility created
by high-flow hemorrhage. As of 2015, 50 cases of ICA
injury during EES were reported in the literature with most
articles detailing successful management and no adverse
experience hamper efforts to establish best practices for intra-
operative management.
1
School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
2
Department of Neurological Surgery, School of Medicine, University of
Pittsburgh, Pittsburgh, Pennsylvania
3
Department of Otolaryngology, School of Medicine, University of
Pittsburgh, Pittsburgh, Pennsylvania
Corresponding Author:
Carl Snyderman, UPMC Center for Cranial Base Surgery, 203 Lothrop
Street, Eye & Ear Institute, Suite 500, Pittsburgh, PA 15213, USA.
Email: snydermanch@upmc.edu
Presented as an on-demand virtual lecture at the North American Skull Base
Society Annual Meeting, February 13, 2021.
2 American Journal of Rhinology & Allergy
There are many considerations when managing an ICA
injury. Knowing the necessary equipment to have on hand,
choosing the best strategy to obtain hemostasis, and under-
standing how and when the vessel can be sacrificed are just
a few of these considerations. Indeed, there is a wide
variety of tools and techniques that may be employed to
manage an ICA injury and choosing the best approach
during the crisis can be an overwhelming task. For surgeons
experiencing ICA injury for the first time, prior practice and
knowledge of established guidelines can ensure success and
limit morbidity.
To date, many efforts have been made to elucidate the best
methods for managing ICA injuries. In some cases, full-
length protocols have been suggested by highly experienced
surgeons from tertiary care centers.4 In others, animal or
cadaver-based simulations of ICA injuries have been used
to validate tools and techniques.5–7 Additionally, multicenter
case series are invaluable sources of lessons learned. There is
no universal consensus, however, regarding the best methods
for managing ICA injury. This study seeks to address this
need. Using the Delphi method, we sought to consolidate
the practices and opinions of experienced skull base surgeons
from high-volume tertiary care centers into a single consen-
sus statement regarding the best practices for managing
ICA injuries during EES.
Methods
The Delphi method is a research technique for achieving con-
sensus among a group of experts. It has been used widely in
medical research to identify best practices for treating illness
and managing complications of care8–13 The technique
involves multiple rounds wherein participants anonymously
share their opinions or experiences on a given subject with
the rest of the cohort. In each round, participants are asked
to reshare their opinions/experiences but are allowed to
revise their statements in light of the opinions of other partic-
ipants from the previous round. As such, each subsequent
round results in greater convergence of opinion. In theory,
the process can be repeated until a complete consensus of
opinion is reached or until there is no longer a significant
change in responses; however, in most cases, the number
of rounds is predetermined.14
Approval was obtained from our Institutional Review
Board (PRO16090072) for this study. The Delphi method
for this study included 3 rounds. In round 1, an evidence-
based review of the literature was carried out to generate
a 13 question, multiple-choice survey that assessed prac-
tices and opinions regarding various aspects of ICA injury
management (Table 1). The multiple-choice format was
chosen to make the survey easier to complete, but partici-
pants were allowed to give free-text responses if none of
the available choices captured their practices or opinions.
Participants were allowed to select more than 1 answer
for each question.
In round 2, all responses were converted into statements/
proposed guidelines. All statements fell under 1 of 4 catego-
ries: “pre-operative management and equipment for high-risk
patients,” “hemorrhage control,” “definitive management,”
and “pharmacologic treatment, blood pressure, and neuro-
physiologic monitoring.” In cases where an answer choice
was not selected by any participants, that answer choice
was converted to a “negative statement.” For example, if
no participant selected suturing as an acceptable way of con-
trolling a small ICA tear then the statement “suturing should
not be used to repair a small ICA tear” was incorporated into
the list. A complete list of statements was circulated among
all participants who were then asked to rank their agreement
with each statement on a 9-point Likert scale (1 = completely
disagree; 9 = completely agree). Participants were also
invited to provide free-text explanations for their answers
or comment on the clarity of the statements.
Statements were recirculated in round 3 and participants
were once again asked to rank their agreement (where neces-
sary, statements were revised to enhance clarity according to
the recommendations of the panel). However, this time par-
ticipants could view the responses of other participants
from the previous round—all responses were reported
anonymously.
Consistent with the recommendations of the American
Academy of Otolaryngology Head and Neck Surgery
(AAO-HNS), consensus was defined in terms of mean scores
and the number of outliers (defined as responses of >2 points
below the mean) for each statement. Statements with mean
scores ≥7 with no more than 1 outlier were classified as
having consensus. Those with a mean score ≥6.5 with no
more than 2 outliers were classified as having near consensus.
All other statements were classified as having no consensus.15
The composition of the cohort also followed the recom-
mendations outlined by the AAO-HNS.15 In total, we
intended to include 11 to 25 participants in the study.
Invitations to participate in the study were distributed
among skull base surgeons at tertiary care centers across
the country in an attempt to achieve broad geographic repre-
sentation. Moreover, invitations were sent to both neurosur-
gery and otolaryngology skull base surgeons in an effort to
capture the perspectives of the 2 main “stakeholders”
involved in ICA injury repair. Specifically, invitations to neu-
rosurgeons and otolaryngologists were distributed in an
approximate 2:1 ratio to reflect the proportionate experience
of the 2 specialties in managing ICA injuries, respectively.
In addition to the questions relevant to the Delphi method,
participants were asked if they had ever experienced an
ICA injury during EES and, on a scale of 1 (completely
unconfident) to 9 (completely confident) what their level of
confidence was regarding the management of carotid injuries.
Given the highly technical nature of the topic at hand, it was
felt that other stakeholders (anesthesiologists, patients,
nurses, etc) would not be able to give informed input and
therefore were not included in this study.
Kassir et al. 3

Table 1. Questions for Delphi Round 1.

1. Which of the following preparations would you make for a patient at high risk of ICA injury?
A: Pre-op MRI
B: Pre-op CTA
C: Pre-op BOT
D: Surgical navigation
E: Neurophysiological monitoring with SSEPs
F: Central line for infusion
G: Single peripheral line for infusion
H: 2 peripheral lines for infusion
I: Preop femoral cannulation for angiography or endovascular management
J: Preparation of the neck for transcervical access to the ICA
K: Other (please specify)

2. What equipment do you believe is necessary to have in the OR in anticipation of an ICA injury?
A: Cottonoids
B: Bipolar electrocautery
C: Endoscopic needle holder or suture device
D: Doppler probe
E: Aneurysm clips (and endoscopic aneurysm clip applier)
F: C-arm/fluoroscopy
G: 2 units of blood in the OR
H: 2 units of blood on hold
I: Other (please specify)

3. What is your method for stopping bleeding from a small (2-3 mm) ICA injury or tear of an accessory branch?
A: Bipolar electrocautery
B: Packing the entire nasal cavity
C: Cottonoids + focal pressure
D: Cottonoids + crushed muscle + focal pressure
E: Cottonoids + focal pressure + other hemostatic material (Floseal, etc)
F: Tachosil glue or other allograft
G: Reconstruction of the vessel wall (without occlusion) with an aneurysm clip
H: Suturing
I: Other (please specify)

4. What is your method for stopping bleeding from a large (>3 mm) ICA injury?
A: Bipolar electrocautery
B: Packing the entire nasal cavity
C: Cottonoids + focal pressure
D: Cottonoids + crushed muscle + focal pressure
E: Cottonoids + focal pressure + other hemostatic material (Floseal, etc)
F: Tachosil glue or other allograft
G: Reconstruction of the vessel wall (without occlusion) with an aneurysm clip
H: Suturing
I: Other (please specify)

5. From where would you preferentially harvest crushed muscle?

A: Temporalis
B: Thigh
C: Rectus abdominis
D: Tongue
E: Longus capitis
F: I do not harvest crushed muscle
G: Other (please specify)
(continued)
4 American Journal of Rhinology & Allergy

Table 1. Continued.

6. What pharmacologic agents would you use during an ICA injury?

A: Heparin bolus to prevent thrombus
B: Adenosine for induction of temporary cardiac arrest
C: Indocyanine green dye for fluoroscopy
D: Would not use any of these
E: Other (please specify)

7. Which of the following are acceptable methods for gaining proximal control of an ICA injury?
A: Digital compression of the ICA in the neck
B: Dissecting the neck and clamping the common carotid artery
C: Dissecting the neck and clamping the ICA at its origin
D: Placing pressure on the ICA proximal to the injury endonasally
E: Placing an aneurysm clip proximal to the injury endonasally
F: Femoral cannulation and inflating a balloon proximal to the injury
G: I never try to obtain proximal control of an ICA injury
H: Other (please specify)

8. Which of the following is true regarding ICA sacrifice?

A: I would sacrifice the ICA to resolve an ICA injury before considering bypass or stent placement
B: I would sacrifice the ICA if I could not otherwise control the bleeding even if the patient failed a BOT
C: I would sacrifice the ICA only if the patient passed a BOT
D: I would never sacrifice the ICA
E: Other (please specify)

9. If necessary, how would you sacrifice the ICA? (this question did not appear if D was selected in question 8)
A: Compress the ICA with packing endonasally
B: Place aneurysm clips endonasally
C: Ligate the ICA in the neck
D: Perform endovascular coiling of the ICA
E: Other (please specify)

10. Which of the following is true regarding stent/flow-diverter placement?

A: I would preferentially use a stent to resolve an ICA injury before considering sacrifice or bypass regardless of the results of a BOT
B: I would only use a stent if a patient failed a BOT
C: If a patient failed a BOT, I would preferentially use a stent to resolve an ICA injury before considering bypass
D: I would never attempt to preserve the ICA using a stent
E: Other (please specify)

11. Which of the following is true regarding ICA bypass?

A: I would preferentially attempt an ICA bypass to resolve an ICA injury before considering sacrifice or stent placement
B: If a patient failed a BOT, I would preferentially attempt ICA bypass before stent placement
C: I would attempt an ICA bypass but only after the patient failed a BOT and stent placement was ruled out as an option
D: I would never attempt an ICA bypass
E: Other (please specify)

12. How would you manage a patient’s blood pressure during an ICA injury?
A: I would elevate mean arterial pressure (>90 mm Hg)
B: I would maintain normal mean arterial pressure (80-90 mm Hg)
C: I maintain a low mean arterial pressure (<80 mm Hg)
D: Other (please specify)

13. If evoked potentials changed during your management of an ICA injury, how would you respond?
A: Elevate blood pressure
B: Readjust packing
C: Obtain an angiogram emergently
D: I do not use SSEP monitoring during my cases
E: Other (please specify)
Abbreviations: MRI, magnetic resonance imaging; CTA, computed tomography angiography; ICA, internal carotid artery; SSEP, somatosensory evoked potential;
OR, operating room.
Kassir et al. 5

Table 2. Characteristics of Participating Skull Base Surgeons. Table 3. Statements Reaching Consensus and Near Consensus
Regarding Preoperative Management and Equipment for High-risk
Participants Patients.
Characteristics (n = 23)
Consensus Near consensus
Male surgeons (n, %) 21 (91.3)
Surgeons based in United States (n, %) 22 (95.7) Preoperative MRI is necessary for Aneurysm clips and clip
Skull base otolaryngologists (n, %) 8 (34.8) patients with a high risk of ICA applier are necessary to
Skull base neurosurgeons (n, %) 15 (65.2) injury have in the OR for a patient
Affiliation with a University Hospital (n, %) 23 (100) with a high risk of ICA injury
Years since fellowship completion (mean, SD) 15.6 (8.1) Preoperative CTA is necessary for
Surgeons having experienced at least 1 internal 20 (87.0) patients with a high risk of ICA
carotid artery (ICA) injury (n, %) injury
Placing 2 peripheral lines for
perfusion is necessary for
Results patients with a high risk of ICA
injury
The characteristics of our cohort are presented in Table 2. Intraoperative surgical navigation is
In total, 23 skull base surgeons (15 neurosurgeons and 8 oto- necessary for patients with a high
laryngologists) participated in the Delphi method with 18 risk of ICA injury
universities (17 in the United States and 1 in Australia) rep- Neurophysiologic monitoring with
resented among participants. Participants reported a mean somatosensory evoked potentials
score of 7.7 regarding confidence in managing ICA injuries. is necessary for patients with a
All but 3 participants had previously experienced an ICA high risk of ICA injury
injury at least once during their careers. Cottonoids are necessary to have
in the OR for patients with a high
After all participants completed the initial 13 question
risk of ICA injury
survey, a list of 63 proposed guidelines was circulated for con- Bipolar electrocautery is necessary
sideration in rounds 2 and 3. At the end of the third round, com- to have in the OR for patients
plete consensus was achieved for 31 (49%) statements and near with a high risk of ICA injury
consensus was achieved for 5 (8%) statements. No consensus A doppler probe is necessary to
was achieved on the remaining 27 (43%) statements. have in the OR for patients with a
high risk of ICA injury
It is necessary to have 2 units of
Preoperative Management and Equipment blood in the OR for patients with
for High-risk Patients a high risk of ICA injury
It is necessary to have 2 units of
Regarding preoperative management and equipment for high- blood on hold for patients with a
risk patients, 10 statements achieved full consensus while 1 high risk of ICA injury
achieved near consensus (Table 3). Participating surgeons
reached consensus that both preop magnetic resonance Abbreviations: MRI, magnetic resonance imaging; CTA, computed
tomography angiography; ICA, internal carotid artery; OR, operating room.
imaging (MRI) and computed tomography angiography
(CTA) were necessary for patients at high risk of ICA injury.
In addition, high-risk patients should have 2 peripheral the injury. While bipolar electrocautery and a combination of
lines placed in anticipation of rapid infusion while cottonoids and focal pressure alone were deemed effective for
neurophysiologic monitoring with somatosensory evoked small (2-3 mm) ICA tears or injury to an accessory branch,
potential (SSEP) and intraoperative surgical navigation are both interventions were deemed ineffective for large (>3 mm)
also necessary. Regarding other equipment that should be tears. In contrast, a combination of crushed muscle and focal
readily accessible for high-risk patients, consensus was achieved pressure was deemed an acceptable strategy for both tear
regarding cottonoids, bipolar electrocautery, a doppler probe, sizes and was the only strategy deemed acceptable to control
and blood products (2 units in the operating room (OR) and bleeding from a large tear. Acceptable sites for crushed
2 units on hold). Near consensus was also obtained that muscle harvesting included the thigh, rectus abdominis, and
aneurysm clips and a clip applier should be available. temporalis muscles. A consensus was reached that flowable
gelfoam (Surgifoam®, Floseal®, Surgiflo®) should not be used
to repair carotid injuries of any size and that suturing should
Hemorrhage Control not be used to repair small tears. A near consensus was achieved
Regarding hemorrhage control, 11 statements reached full con- that suturing should not be used to repair large tears as well.
sensus while 3 reached near consensus (Table 4). Statements The only 2 options for proximal control that were included in
that achieved consensus differed with respect to the size of the final consensus statement (both having achieved near
6 American Journal of Rhinology & Allergy

Table 4. Statements Reaching Consensus and Near Consensus Table 5. Statements Reaching Consensus and Near Consensus
Regarding Hemorrhage Control. Regarding Definitive Management.

Consensus Near consensus Near

Consensus consensus
A combination of cottonoids and Suturing should not be
focal pressure alone can be attempted to repair a large If an ICA bleed cannot otherwise be controlled,
attempted to control bleeding tear ICA sacrifice should be considered regardless of
from a small tear the results of a BOT
A combination of cottonoids and Placing an aneurysm clip If ICA vessel sacrifice is necessary, endovascular
focal pressure alone should not proximal to the injury coiling is the preferred method
be used to control bleeding from endonasally is an effective One should always preferentially use a stent/flow
a large tear method of gaining proximal diverter to resolve an ICA injury before
control of an internal carotid considering sacrifice or bypass regardless of the
artery (ICA) injury results of a BOT
Bipolar electrocautery can be Dissecting the neck and clamping ICA bypass should be attempted only after a
used to control bleeding from a the ICA at its origin is an effective patient fails a BOT and stent/flow diverter
small tear method of gaining proximal placement is ruled out as an option
control of an ICA injury
Abbreviations: ICA, internal carotid artery; BOT, balloon occlusion test.
Bipolar electrocautery should not
be used to control bleeding from
a large tear
Table 6. Statements Reaching Consensus and Near Consensus
A combination of cottonoid,
Regarding Pharmacologic Management, Neurophysiologic
crushed muscle, and focal
Monitoring, and Blood Pressure Control.
pressure can be used to control
bleeding from a small tear Consensus Near consensus
A combination of cottonoid,
crushed muscle, and focal Heparin should be given to ASA should be given to prevent
pressure can be used to control prevent thrombus while thrombus after repair of an
bleeding from a large tear repairing an ICA injury ICA injury
It is acceptable to harvest crushed Adenosine for inducing
muscle from the thigh temporary cardiac arrest can
It is acceptable to harvest crushed be useful when repairing an
muscle from the temporalis muscle ICA injury
It is acceptable to harvest crushed One should maintain a normal
muscle from the rectus (80-90) or high (>90) mean
abdominis muscle arterial pressure while
Morselized Gelfoam should not managing a carotid injury
be used to repair small or large If the SSEP signals changed, I
ICA tears would elevate the mean arterial
Suturing should not be attempted blood pressure
to repair a small tear If the SSEP signals changed, I
would readjust any packing
If the SSEP signals changed, I
consensus) were the placement of an aneurysm clip proximal to would obtain an angiogram
the injury endonasally as well as dissecting the neck and clamp- emergently
ing the ICA at its origin. Abbreviations: ICA, internal carotid artery; SSEP, somatosensory evoked
potential.

Definitive Management
Regarding definitive management, 11 statements reached full
consensus while 3 reached near consensus (Table 5). All pro-
posed guidelines had to do with 1 of 3 options: sacrifice,
stent/flow-diverter placement, or bypass. By the end of round
3, consensus was reached that stent/flow-diverter placement
should be considered first-line therapy for definitive manage-
ment regardless of the results of a balloon occlusion test
(BOT). Nonetheless, in cases where the bleeding cannot other-
wise be controlled, sacrifice should be considered regardless of
the results of a BOT and is best achieved through endovascular
coil embolization. A consensus was also reached that ICA
bypass should be considered a last resort when stent placement
was not possible and the patient had failed a BOT.
Pharmacologic Management, Neurophysiologic
Monitoring, and Blood Pressure Control
Regarding pharmacologic management, neurophysiologic
monitoring, and blood pressure control, 6 statements
Kassir et al.
achieved full consensus while 1 achieved near consensus
(Table 6). Adenosine and heparin were both identified as
agents with important uses during an ICA injury.
In the postoperative period, aspirin is advised to prevent
thrombus/embolus formation. Consensus was reached that
mean arterial pressure should be kept normal or elevated
while managing an ICA injury. Correspondingly, planned
hypotension during the crisis is inadvisable. As previously
established, neurophysiological monitoring with SSEPs has
an important role, and the consensus statement promotes a
3-pronged approach when signals change: elevate the
patient’s blood pressure, readjust any packing, and obtain
an angiogram emergently.
Discussion
This study is unique in its effort to develop a consensus state-
ment regarding the management of ICA injury during EES.
This consensus statement represents the experiences and
opinions of 23 skull base surgeons from high-volume tertiary
care centers with a broad geographic distribution. Simply put,
there are numerous decisions that a surgeon must make when
facing a carotid injury. Based on this process, many questions
can be grouped under 1 of the 4 categories outlined in the
consensus statement and can be clearly addressed by the find-
ings, providing a framework for any surgeon facing these
injuries.
There are a number of necessities identified for the preop-
erative planning of high-risk patients. High-risk factors
include malignancy involving the ICA, recurrence after radi-
ation with ICA involvement, narrowing or encasement of the
ICA, and patient factors such a vasculopathy, coagulopathy,
connective tissue disease, etc. For these patients, imaging is
an essential component of the preoperative workup and has
been shown to decrease the rate of complications of EES.16
The combination of MRI and CTA advised in the final con-
sensus statement provides a thorough understanding of the
relationship between critical vascular structures and the
target lesion. Not only is this necessary to plan an optimal
surgical approach, but identifying ICA encasement or dis-
placement or tumor invasion of the vessel wall can alert sur-
geons to the possibility (and sometimes inevitability) of
carotid injury during EES,17 warranting anticipatory mea-
sures like acquisition of abundant blood products and dual
intravenous placement for rapid infusion and the need for
preoperative BOT to prepare for possible ICA sacrifice.
Furthermore, it is worth noting the importance this consensus
places on technologies. As confirmed by the extant literature,
intraoperative surgical navigation,18 doppler ultrasonography
for carotid localization,19,20 and SSEP monitoring21 have
been shown to prevent or improve outcomes from vascular
injury during EES. They do so, in general, by helping to pre-
cisely localize the ICA as well as providing an intraoperative
understanding of the physiologic impact of management
strategies. It is simultaneously worth noting that these tools
7
may not be readily available at all medical centers due to
cost and surgical routines.22 As such, referral of a high-risk
patient to a center where this technology is readily available
may be warranted.
The consensus statement also identifies more simplistic
but critical tools like cottonoids and bipolar cautery as neces-
sary pieces of equipment and elaborates on how these may be
used to achieve initial control of the hemorrhage. Intuitively,
applying nonocclusive focal pressure with a cottonoid and
waiting for hemostasis is the simplest method for stopping an
ICA bleed and is indicated for small tears. According to the
results of the Delphi method, however, this approach is not
advisable for large tears. Bipolar electrocautery, another
easily employed technique, is viewed similarly. Simply put,
when it comes to controlling bleeding from large tears, full con-
sensus was reached on only 1 of the proposed measures—the
utilization of crushed muscle. Indeed, the efficacy of crushed
muscle has become widely established in the literature with
prior research specifically demonstrating its superiority to
other hemostatic agents including Floseal and oxidized regen-
erated cellulose.6,23,24 In terms of the optimal site for harvesting
muscle, the consensus statement endorses almost any of the
sites suggested in our survey (temporalis, thigh, and rectus
abdominis) but no consensus was reached for the longus
capitis or tongue. It is worth noting that the longus capitis
has only recently been suggested as a donor site.6
While suturing is widely recommended as an option to
repair an ICA tear4,17,24 our findings suggest that this
should generally be avoided endonasally. The degree of dif-
ficulty involved in suturing through the endonasal approach
can be prohibitive, and the attempt can waste precious
time.25 As commented by 1 of our participants in the final
round, “I would consider suturing in an open case, but I
have never seen it work endonasally.”
In cases of severe injury, it may be necessary to obtain
proximal control of the ICA before achieving hemostasis.
However, only 2 of the proposed methods were included in
the consensus statement (both achieving near consensus).
Five participants stated that they would employ cervical
proximal control only if the injury occurred on or near the
petrous ICA segment, which is congruent with Gardner
et al.25 who stated that proximal control through a cervical
incision is best employed when the tear is in the horizontal
petrous, lacerum, or parapharyngeal ICA segments. Placing
an aneurysm clip is indicated for more distal segments (para-
clival and parasellar). Regarding the placement of endonasal
aneurysm clips for proximal control, the near consensus we
obtained is also consistent with this paper which stated that
this often requires further exposure of the injured ICA
segment as well as the placement of a distal clip, making
this a potentially taxing and time-consuming strategy that,
while effective, may not always be achievable.
After gaining control of an ICA bleed, it is widely
accepted that the patient should undergo immediate angiog-
raphy and evaluation for definitive management.4,17,24,25
8 American Journal of Rhinology & Allergy
Participants were asked to share their opinions regarding 3
options for definitive management: sacrifice of the ICA,
endovascular stenting, and surgical bypass. Choosing
between sacrifice and stent/flow-diverter placement is, in par-
ticular, often challenging. Sacrifice, on the one hand, is main-
tained by many to be first-line due to its efficiency and
reliability in resolving a bleeding vessel.26–28 It is well toler-
ated by most with ∼80% of patients possessing sufficient col-
lateral circulation to withstand the maneuver without
postoperative deficits.4,17 Placing aneurysm clips proximal
and distal to the injury endonasally is one method with dem-
onstrated efficacy; the need to fully expose the injured ICA
segment (often difficult and time consuming) can make this
untenable.29 In centers with ready access to interventional
services (radiology, neurology, or neurosurgery) and espe-
cially with the growing prevalence of hybrid ORs, sacrifice
by endovascular means has become an alternative that
offers greater expediency and effectiveness in cases when
the injury is too difficult to manage endonasally. According
to the consensus statement, embolization with coils is pre-
ferred to external methods of sacrifice. Stenting, on the
other hand, has been shown to be safe and effective,26,30,31
but is technically difficult (especially when the ICA is
kinked or if the injury is at or past the cavernous segment),
and runs the risk of worsening the injury.17 Even still, one
can intuitively appreciate that maintaining the patency of
both carotids is preferable as future incidence of trauma, ath-
erosclerosis, or other cause of stenosis cannot be predicted in
addition to the risk of flow-related aneurysms (especially in a
young patient). This logic is consistent with the consensus
reached by our Delphi participants that stent/flow-diverter
placement is preferable to sacrifice even when collateral cir-
culation is confirmed. In general, bypass is reserved for situa-
tions when the patient is known to lack collateral circulation
(and therefore cannot tolerate sacrifice) and when stent place-
ment has failed or is otherwise untenable. However, it may be
the only option if interventional services are not available.
Indeed, when it comes to definitive management, the impor-
tance of having access to interventionalists cannot be over-
stated. For medical centers lacking access to this resource,
transfer of high-risk patients to tertiary care centers is
advisable.
The final consensus statement also elaborates on the phar-
macologic management of ICA injuries during EES.
Regarding adenosine, administration induces transient hypo-
tension which can attenuate severe bleeding and enhance vis-
ibility long enough for hemostatic agents to be applied. While
previously used during intracranial aneurysm surgery, adeno-
sine is a relatively new concept for EES with the first reports
of its safety and effectiveness coming from Fastenberg
et al32 in 2019. At present, the limited literature suggests that
adenosine has the potential to be a safe and effective adjuvant
measure in cases where an ICA bleed is otherwise uncontrol-
lable endonasally.32,33 The results of this consensus statement
corroborate these findings and should serve to further
encourage surgeons to add adenosine to their toolbox in
cases with a high risk of ICA injury. Additionally, while coun-
terintuitive in the setting of acute hemorrhage, heparin helps to
prevent an embolic phenomenon that may occur secondary to
injury to the vessel wall or repetitive manipulation.4 Moreover,
aspirin is recommended by consensus to prevent embolic phe-
nomenon in the postoperative period.
Finally, we asked participants to share their opinions
regarding blood pressure and neurophysiologic monitoring
during EES. Consistent with recommendations made by
AlQahtani et al4 and Gardner et al,17 the final consensus
statement dictates that blood pressures should be kept
normal to high during the management of an ICA injury.
Presumably, while a state of hypoperfusion may make the
bleed easier to control, ensuring adequate cerebral perfusion
is paramount. Our participants also reached a consensus that
SSEP monitoring plays an important role in ICA injury man-
agement. In particular, SSEP can help guide permissive
hypotension while avoiding hypoperfusion and changes in
evoked potentials during the course of the crisis could indi-
cate an embolic phenomenon or potentially the unintentional
occlusion of the ICA lumen by the surgeon.21 This consensus
statement advocates for a straightforward, 3-pronged
approach which includes elevating the patient’s blood pres-
sure, readjusting any packing, and obtaining an angiogram
emergently to assess for occlusion at any point along the
vessel.
Limitations of this study warrant discussion. Most
notably, the cohort for this study was made up almost entirely
of skull base surgeons practicing in the United States which
may limit the generalizability of our findings in the interna-
tional skull base community. Additionally, while the consen-
sus statement is based on a consensus of expert opinion, we
offer no evidence regarding its efficacy.
Future efforts should be made to validate the efficacy of
our consensus statement. At present, there is a growing
body of literature using simulation models of ICA injury so
that surgeons can gain experience managing the crisis.
Perfusion-based human cadaver and animal models, in par-
ticular, can provide realistic training environments for this
purpose.34–36 We propose teaching this consensus statement
to novice surgeons and assessing how this may impact effi-
ciency and outcomes in managing artificial ICA injuries.
Demonstrable efficacy in this setting could validate the use
of this consensus statement for real-world situations. At the
very least, it is hoped that it will provide a strong framework
for surgical teams to build their own protocols.
Conclusions
This study helps to identify best practices for managing ICA
injury during EES based on consensus of expert opinion. The
final consensus statement is comprehensive in its scope,
offering guidance for preoperative preparations, materials
and techniques for hemorrhage control and definitive
Kassir et al.
management, and the roles of blood-pressure monitoring,
neurophysiologic monitoring, and pharmacologic agents for
resolving a carotid injury. The efficacy of this consensus
statement should be investigated using simulation technol-
ogy to validate its use for real-world situations. At the very
least, it offers a tool to the skull base community that can
act as a framework for management of ICA injury during
EES to improve outcomes.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: None
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
Ethical Approval
Approval was obtained from our Institutional Review Board
(PRO16090072) for this study.
Informed Consent
Not applicable, because this article does not contain any studies with
human or animal subjects.
Trial Registration
Not applicable, because this article does not contain any clinical
trials.
ORCID iD
Carl H. Snyderman https://orcid.org/0000-0002-8920-4522
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