Journal of Vascular Surgery
Volume 51, Issue 2 , Pages 323-329, February 2010

Open surgical reconstruction of the internal carotid artery aneurysm at the base of the skull

  • Serguei Malikov, MD, PhD

      Affiliations

    • Service de Chirurgie Vasculaire, Faculté de Médecine de Marseille, Hôpital de la Timone, Marseille, France
    • Corresponding Author InformationReprint requests: Serguei Malikov, MD, PhD, Service de Chirurgie Vasculaire, CHU Timone, 13385 Marseille, France
    • ,
  • Jean Marc Thomassin, MD

      Affiliations

    • Service d'Oto-Rhino-Laryngologie, Faculté de Médecine de Marseille, Hôpital de la Timone, Marseille, France
    • ,
  • Pierre Edouard Magnan, MD

      Affiliations

    • Service de Chirurgie Vasculaire, Faculté de Médecine de Marseille, Hôpital de la Timone, Marseille, France
    • ,
  • Grigol Keshelava, MD

      Affiliations

    • Service de Chirurgie Vasculaire, Faculté de Médecine de Marseille, Hôpital de la Timone, Marseille, France
    • ,
  • Michel Bartoli, MD

      Affiliations

    • Service de Chirurgie Vasculaire, Faculté de Médecine de Marseille, Hôpital de la Timone, Marseille, France
    • ,
  • Alain Branchereau, MD

      Affiliations

    • Service de Chirurgie Vasculaire, Faculté de Médecine de Marseille, Hôpital de la Timone, Marseille, France

Received 3 June 2009; accepted 22 August 2009.

Article Outline

Objectives

Aneurysms of the internal carotid artery (ICA) at the base of the skull are uncommon dangerous lesions whose management remains unclear. The aim of this retrospective study is to report a standardized surgical technique of ICA reconstruction with long-term results.

Methods

Between 1988 and 2005, 13 patients (11 men; age 18 to 76 years, mean 42.6 years) underwent lateral skull base approach with cervical-to-petrous carotid artery bypass for repair of ICA aneurysms. Principal elements of the technique were: partial resection of the parotid gland without rerouting of the facial nerve; luxation of mandibula; drilling of the bone.

Results

The 13 patients had unilateral aneurysm of the ICA at the base of the skull. Four aneurysms were of atherosclerotic origin; six fibromuscular dysplasia; two post-traumatic; one cause was undetermined. The mean diameter of the aneurysms was 12 mm (range, 7-21 mm). Twelve patients were symptomatic: six presented neurological events (four strokes, two transient ischemic attack [TIA]); two retinal events; three compressive symptoms (two Horner's syndrome and one paralysis of the glossopharyngeal nerve); one patient presented a visible pulsatile mass in the neck. One patient was asymptomatic. There were no post-operative deaths, one TIA, 13 transient palsies of the lower facial nerve, and one transient palsy of accessory nerve. Palsy of cranial nerves was partial and disappeared within a mean of 5.6 months (range, 1-10 months). The postoperative angiogram showed patency in all but one case (one asymptomatic thrombosis). During follow-up (mean, 152 months), there was one unrelated death, one focal epileptic seizure, and one controlateral TIA. In November 2008, duplex showed patency of all 11 grafts (one death, one thrombosis). At 10 years, the survival, cumulative stroke-free survival, ipsilateral stroke-free, and patency rates was were 90.9%, 100%, 100%, and 92.3%.

Conclusion

Venous graft bypass from the cervical-to-petrous ICA can be performed safely with such an approach and produces durable satisfactory results.

 

Aneurysms of the extracranial internal carotid artery (ICA) are uncommon lesions. Schechter found 853 cases in 820 patients, in a literature review from 1687 to 1977.1 Aneurysms of the ICA developed at the base of the skull in the infra-temporal fossa are even more rare.2 Prevention of thrombo-embolic events is the main indication for surgical procedures. Treatment by ligature of the ICA is accompanied with a risk of stroke up to 30%.3, 4 The surgical approach of these lesions faces anatomical difficulties due to the complexity of the region and the close relation between the ICA and the cranial nerves, mainly the facial nerve. Along the 20 last years of the 20th century, several surgical teams proposed solutions to control the ICA in the infra-temporal fossa and to reconstruct it. These techniques had multiple drawbacks and were associated with some permanent morbidity. Thus, for many, these lesions were considered as nonoperable. The endovascular treatment looks particularly attractive in this situation but there are no series reported in the literature, only some case reports with uncertainty of the results.5, 6, 7

From 1988, we studied in our institution this problem in combination with the ears, nose, and throat (ENT) surgeons. We set up a technical approach allowing control of the ICA up to the first segment of the petrous canal associated with minimal morbidity.2, 8, 9, 10 With this technique, we treated 13 patients presenting with aneurysm of the ICA at the base of the skull. To the best of our knowledge, this study is the first to present a series of such lesions repaired by reconstructive surgery. The aim of this study is to describe the technique and to report the short and long-term results with a follow-up ranging from 38 months to 242 months.

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Methods 

Operative procedure 

All aneurysms were treated surgically under general anesthesia with the same protocol by a team composed by ENT and vascular surgeons. The lateral infratemporal approach as previously described2, 10 was used in all cases. The neck was slightly extended, and the head turned opposite the side of the intended incision. Elevation of the shoulders with a rolled sheet enhanced neck extension. The upper chest, neck, head with ear, and leg were draped. The cutaneous incision followed a line with two curves from the postauricular region down to the neck along the anterior border of the sternocleidomastoid muscle (Fig 1). The carotid bifurcation, jugular vein, ICAm and the 10th and 12th cranial nerves were controlled in the usual way. The posterior belly of the digastric muscle was cut off and the 9th cranial nerve identified and preserved. The external auditory canal was cut and put back at the end of the operation. The facial nerve was localized at its emergence from the stylomastoid foramen, then its intraparotid portion exposed. The trunk and the cervicofacial branch were isolated, thanks to a resection of the posterior part of parotid gland. The styloid process was resected and the styloid muscles anteriorly retracted. The mandibular condyle was luxated anteriorly and maintained thanks to a specific retractor. This bone retractor was designed to preserve the open space in the mandibular joint, thereby preventing excessive traction of the facial nerve. The facial nerve crossing the operating field was not mobilized to avoid a postoperative paralysis. The vaginal process and the lower part of the external auditory canal were drilled to expose the first vertical intrapetrous segment of the ICA (Fig 2).

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  • Fig 2. 

    PerI-operative view. Insert: specific retractor. Arrow: ICA. The loop is at the level of the opening of the petrous canal. Double arrow: Facial nerve. ICA, internal carotid artery.

Thanks to this approach, the ICA could be controlled up to its first vertical intraosseous part. The aneurysm was resected in all cases and the ICA replaced by a reversed saphenous vein graft. Histologic evaluation of the ICA aneurysm was performed in all cases. Cerebral monitoring and shunt were not used in this series. Cerebral protection was achieved by the control of arterial pressure and heparinization. Systemic heparinization (100 IU/kg) was used during cross-clamping and neutralized at the end of the procedure after completion angiography.

Postoperatively, the patients were given non fractional intravenous heparin for 24 hours. ASA (acetylsalicylic acid) was used as antiplatelet therapy permanently (65 mg/day-250 mg/day) with the exception of the patients already on anticoagulation medication for concomitant disease.

Patients 

An aneurysm of the ICA was defined as a localized dilation of the arterial lumen higher than 150% of the diameter of the controlateral ICA at the same level. The inclusion criterion was the localization of the ICA aneurysm at the base of the skull in the infratemporal fossa. This anatomical criteria corresponds to the third segment of the cervical ICA (Fig 3) as previously described.2, 11

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  • Fig 3. 

    Division of the ICA in three segments: Segment 1, the bicarotid region. Segment 2, the retrostyloid region. Segment 3, the infratemporal fossa below the penetration into the base of the skull. The oblique line corresponds to the classic Blaisdell line11 between the tip of the mastoid process and the angle of the jaw. ICA, internal carotid artery.

Between January 1988 and August 2005, we performed 2152 ICA surgical reconstructions including 29 aneurysms of the ICA. Within this group of ICA aneurysms, 13 were located in the infratemporal fossa at the base of the skull and are the subject of this study.

Eleven cases occurred in men and two in women, with a mean age of 42.6 years (range, 18-76 years). Twelve patients were symptomatic. Six patients had a localized neurologic event (four strokes, two transient ischemic attacks [TIA]), two patients had retinal events (one amaurosis, one partial amputation of the visual field). Two patients had unilateral headache and Horner's syndrome. One patient had dysphagia due to an isolated paralysis of the glossopharyngeal nerve (IX). One patient had a pulsatile mass in the neck with no other event. One patient had an asymptomatic aneurysm observed during routine carotid artery duplex in a patient treated for ischemic heart disease. The etiology of the thirteen aneurysms is shown in the Table.

Table. Nature of the lesions in this series of 13 aneurysms of the ICA at the base of the skull
PatientGenderAgeDiameter (mm)Etiology
1M1920Fibromuscular dysplasia
2M189Fibromuscular dysplasia
3M4310Unknown
4M4211Post-traumatic
5M5210Atherosclerosis
6M2711Fibromuscular dysplasia
7F4410Atherosclerotic
8M6817Post-traumatic
9M7613Atherosclerosis
10M688Atherosclerosis
11M4910Fibromuscular dysplasia
12M307Fibromuscular dysplasia
13F1921Fibromuscular dysplasia

All patients underwent duplex-scan examination and digital subtraction angiography. Eleven patients had a computed tomography (CT) angiography, with 3D reconstructions, clearly showing the aneurysm of the extracranial ICA at the base of the skull (Fig 4). Six CT scans showed the presence of intraluminal thrombus in the aneurysm. A magnetic resonance imaging was performed in two cases. The mean diameter of the aneurysms was 12 mm (range, 7-21 mm). In four cases, the aneurysms were also extended on the second segment of the cervical ICA, corresponding to the retrostylian region. Eleven patients underwent brain CT scan, which was normal in seven cases and showed an ipsilateral ischemic lesion in four cases.

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  • Fig 4. 

    CT scan: with maximum intensity projection (left) and 3D reconstruction (right) of a fibromuscular dysplasic voluminous aneurysm at the contact of the base of the skull. This type of imaging allows to determine precisely the relationship between the aneurysm and the osseous elements. CT, Computed tomography.

All patients had been referred by other medical centers. The mean interval of time between the onset of the neurologic symptoms and the intervention was 17 days, ranging from 7 to 46 days. The patients presenting with focal neurological or retinal events were treated with heparin. One patient reproduced TIA while waiting for surgery.

Intraoperative data 

All aneurysms were treated surgically under general anesthesia by the same protocol, maintaining a normotensive and normocapnic status without any cerebral monitoring. No intraluminal shunting was used in any patient. The donor artery for the proximal anastomosis was the common carotid artery in 10 cases and the ICA in three cases. Distal anastomosis was performed on the ICA exposed at the level of its first vertical intrapetrous part in all cases. The material of the bypass was the great saphenous vein in all cases. All 13 reconstructions were patent on completion angiography. The mean operating time was 3 hours and 40 minutes (range, 2 hours and 45 minutes to 4 hours and 30 minutes). The mean clamping time was 40 minutes (range, 25-70 minutes).

Post-operative surveillance and follow-up 

The localized neurological events and retinal events were entered into a database. Patients were reviewed daily for the first seven days and thereafter, as required until wound healing and facial palsy regression were completed. All patients were evaluated by postoperative angiography or angio-CT scan between the fifth and the 20th postoperative day.

The first follow-up visit was at one month post-operatively; the following visits were at three, six, and 12 months, then annually. The elements checked during follow-up visits included bypass patency recorded by duplex, localized neurological events, facial palsy regression, and healing.

Statistics 

Patient survival, graft patency, and neurological events were calculated with Kaplan-Meier method with 95% confidence interval. All statistical analyses were performed using SPSS 15.0 software (SPSS for Windows, SPSS, Chicago, Ill).

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Results 

Post-operative results 

No post-operative stroke or death were observed during the first postoperative month. One patient suffered TIA. All patients had transient facial paralysis. In all cases the facial paralysis was partial, involving only the lower branch of the nerve, preserving the closure of the eyelid, and disappeared totally within 10 months (range, 1-10 months; mean, 5.6 months) (Fig 5). One transient accessory nerve paralysis was observed, completely resolving in two months. Swallowing and feeding was possible in all cases between the first and third postoperative day. Twelve reconstructions were patent on the postoperative angiogram or angio-CT (Fig 6). One patient with an undiagnosed dissection extended into the petrous canal had an asymptomatic postoperative occlusion of the venous graft evidenced on angio-CT at the fifth day. Mean duration of hospital stay was 15.4 days (range, 12-26 days) due to feeding rehabilitation (see discussion).

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  • Fig 5. 

    Picture of one of the patients of this series at the fifth post-operative day. Note the discrete palsy of the lower facial nerve without trouble on the higher territory.

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  • Fig 6. 

    Postoperative CT-angiogram of a venous graft. The arrow on the right corresponds to the resection of the mastoid and the vaginal processes. CT, Computed tomography.

Long-term results 

Mean follow-up time was 152 months (range, 39-251 months). No patient was lost to follow-up. One patient died of myocardial infarction at 119 months postoperatively. This patient was stroke-free with a patent graft at the duplex control at 112 months. One patient experienced an epileptic crisis two months after the operation as a result of a preoperative stroke. One patient presented TIA from a cardiac embolus 25 months after the intervention. The patient with postoperative graft occlusion was asymptomatic.

A review of the 12 surviving patients was done in November 2008. The duplex showed patency of 11 bypasses (one death, one immediate postoperative thrombosis) without significant stenosis. No secondary procedure was necessary. There was no late localized ipsilateral neurologic event.

At 10 years, the survival rate was 90.9% ± 14.5%, the cumulative stroke-free survival rate was 100%; the rate of freedom from ipsilateral stroke was 100%, the by-pass patency rate was 92.3% ± 16.9%.

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Discussion 

This series demonstrates that open surgical repair of the ICA at the base of the skull is feasible with light immediate morbidity and excellent long-term results. The scarcity of the ICA aneurysms and moreover of the aneurysms located at the base of the skull makes it unrealistic to have evidence-based guidelines to manage these lesions. The weaker points of this study are the relatively small number of patients, making it difficult to generalize our conclusions, the absence of control cohort, and no comparative series treated medically or by endovascular techniques. The value of the study is represented by the homogeneity of the lesions, the standardized surgical technique identical in all the cases, and the important long-term follow-up. The number of patients treated and the long-term follow-up makes to our knowledge this series the most important in literature.

The spontaneous progression of an aneurysm is associated with a high risk of neurological events due to thrombo-embolic cerebral complications. Some authors reported mortality in non-operated aneurysms and an unacceptable stroke risk as high as 50%.12, 13, 14 Eight of the 13 of our patients had a localized embolic event as the first sign of an aneurysm. The etiology of ICA aneurysm is multiple including atherosclerosis, fibromuscular dysplasia, post-traumatic, and infectious lesions.15 In the great series,1, 16, 17 dysplastic lesions more or less associated with dissection, and trauma appeared to be the main causes of aneurysms of the ICA. This explains the younger age of the patients compared with the series of atherosclerotic ICA stenosis. This young age pushes to an aggressive approach. The alternatives to surgical repair are ligation of the ICA and ligation of the ICA combined with EC/IC bypass.18 Some cases of endovascular exclusion of such aneurysms by stent-graft have been recently reported.5, 6, 7

The carotid ligation is an undesirable option for distal extracranial ICA lesions due to the high risk of stroke.3, 4, 15 Carotid ligation has been shown to carry a 24% incidence of ischemic complications when used in the treatment of arterial aneurysms.19 The risk of ligation of the ICA cannot be fully estimated by preoperative occlusive tests.20 EC-IC bypass followed by carotid ligation is presumed to lower the stroke risk but does not definitively exclude a thromboembolic event from the occluded artery.21, 22

As a consequence, the direct surgical repair seems to be the best solution, leaving the challenging problem of the approach to the ICA at the base of the skull. The different techniques proposed included one or several of the following maneuvers: osteotomy of the mandibula, rerouting or traction of the facial nerve, sacrifice of the medial ear, all causing permanent or long-lasting sequelae.23, 24, 25, 26, 27, 28, 29, 30 Fisch et al23 first described a technique including rerouting of the facial nerve, and sacrifice of the medial ear. Welsh et al24 reported seven cases of reconstructive surgery of the ICA at the base of the skull using a mandibular osteotomy with a regressive facial palsy in four cases and the impossibility of mastication during three weeks. Pech et al25 included the drill of the mastoid process and some traction on the facial nerve. Glassock et al26 reported the case of an aneurysm located inside the petrous canal, the technique including the division of the facial nerve. Pellegrini et al27 reported two cases of post-traumatic aneurysms using rerouting of the facial nerve with unclear long-term results. In the series of 27 patients by Sandmann et al,17 the carotid canal was opened in four cases only; they observed one objective residual damage of the facial nerve; the long-term results are not reported. Alimi et al28 reported six post-traumatic lesions; their technique includes rerouting of the facial nerve and breaking up of the medial and external ear; as a result they observed one section of the facial nerve and auditory problems in all cases. Eliason et al29 described a technique close to ours; they reported five cases with a maximum follow-up of 65 months; they observed postoperatively one permanent deficit of the 11th cranial nerve and a mild conductive hearing loss. Vikatmaa et al30 report an aggressive technique of midline mandibulotomy, which looks mainly useful for the surgery of the tumors at the base of the skull (three tumors and two aneurysms).

Intraluminal shunting during open surgical repair of the ICA at the base of the skull is feasible.29 In our series, no shunting was used in any patient. Despite the number of studies that have been performed about carotid surgery, there is no consensus about the efficacy of shunting.31 The meta-analyses from Cochrane Library, reflecting the best currently available data, showed no evidence in favor of any method of cerebral monitoring or shunting strategy.32

In our routine practice of ICA reconstruction for atherosclerotic stenosis, the indications of carotid shunting are selective. The decision is made preoperatively on the CT angiographic findings (controlateral occlusion) or due to recent stroke. In this series of isolated ICA lesions without occlusive atherosclerotic disease, the shunt was not indicated according to our policy.

Postoperative stay in this series was longer than usually observed after ICA surgical repair due to swallowing problems necessitating careful progressive feeding for one or two weeks. Furthermore, wound healing at the level of the external auditory meatus, which is repositioned in this technique, required extended surveillance at the beginning of our experience.

Endoluminal stent-grafting provides an attractive treatment option; its role in this situation is still in the early stages of being defined. Arterial dissection, embolism during deployment, stent fracture, intimal hyperplasia, and long-term occlusion are the potential risks associated with these techniques. Successful balloon angioplasty and stenting of stenotic ICA lesions at the base of the skull or within the petrous canal have been reported.33 Some recent reports have advocated the use of endovascular therapy in the treatment of aneurysms of the ICA.6, 7, 32 Most publications are case reports. The series are heterogeneous, including open and endovascular repair, or intra and extra-cranial lesions. No mid- or long-term follow-up in significant number of patients have been published to define the safety and efficacy of these interventions. The most important series includes only four cases, not all at the base of the skull and with a minimum follow-up of 12 months.6 Some authors have reported endograft occlusion highlighting the risk of thromboembolic complications that can occur with these techniques.5, 34, 35 In summary, the literature doesn't allow to conclude currently.

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Conclusion 

Open surgical repair of the aneurysms of the ICA at the base of the skull is feasible with a low immediate morbidity and excellent long-term results. It may be considered as a referent treatment option when endovascular option is presented as a new and attractive solution for these rare and challenging lesions.

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Author contributions 


Conception and design: SM, JT, PM, AB

Analysis and interpretation: SM, JT, AB

Data collection: GK, SM

Writing the article: MS, AB

Critical revision of the article: SM, AB, JT

Final approval of the article: SM, AB, JT

Statistical analysis: PM, MB

Overall responsibility: AB, SM

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References 

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 Competition of interest: none.

 The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest.

PII: S0741-5214(09)01815-1

doi:10.1016/j.jvs.2009.08.084

Journal of Vascular Surgery
Volume 51, Issue 2 , Pages 323-329, February 2010

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