Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades

OBJECTIVE: Internal carotid artery (ICA) injury during sellar dural opening is a potentially catastrophic complication of transsphenoidal surgery. We describe two ICA injuries that occurred early in our endonasal transsphenoidal experience. We then describe our subsequent protocol to prevent this complication in which we use the Doppler probe for carotid localization and micro-hook blades for lateral dural opening. METHODS: All patients undergoing endonasal tumor removal were analyzed since beginning this approach in 1998. Of 631 procedures (585 patients), three patients sustained an ICA injury. RESULTS: In the first 114 procedures (105 patients) in which the Doppler probe was not used and hook blades were used infrequently, two (1.8%) ICA injuries occurred. In both cases, a right nostril approach was used and the left ICA was punctured on dural opening with a straight scalpel; both patients recovered without neurological sequelae. In the subsequent 517 procedures in which the Doppler probe and hook blades were used in all cases, one (0.19%) probable ICA injury occurred during an attempted removal of a cavernous sinus schwannoma, although there was no angiographic evidence of vascular injury. There were no ICA or other intracranial vascular injuries in the last 510 procedures for tumors not solely confined to the cavernous sinus. CONCLUSION: Cavernous carotid localization with the Doppler probe before dural opening and angled hook blades for lateral dural opening can help minimize the risk of ICA injury and are recommended for all transsphenoidal operations. Because of the wider contralateral exposure provided by the endonasal approach, the ICA contralateral to the nostril of approach is at higher risk of injury on dural opening.