Management and outcomes of internal carotid artery, anterior cerebral artery, or middle cerebral artery injury during microsurgical approach of the anterior and middle cranial skull base: insights from a systematic review and a case series

Injury of the internal carotid artery (ICA), anterior cerebral artery (ACA), and middle cerebral artery (MCA) are rare but devastating complications during microsurgery of the anterior and middle cranial skull base. We systematically reviewed the current knowledge on ICA, ACA, and MCA injury during skull base microsurgery and performed a multicentric data collection to refine their management. A systematic review of ICA, ACA, and MCA injuries during direct microsurgical approaches to the anterior and middle cranial skull base was performed, using PRISMA-IPD guidelines and using a multicentric case collection. Literature search (French and English languages, PubMed/MEDLINE) was performed from January 1946 to July 2024. 76 adult patients were included (65 adult from literature review, 11 from multicentric case collection). The injury involved the ICA, ACA, and MCA in 38.2%, 39.5%, and 22.3% of cases, respectively. Death related to the artery injury occurred in 22.4% of cases. Injury of the ICA and intraoperative management by occlusive clipping were independent predictors of death related to the arterial injury. Permanent neurological deficit related to the artery injury occurred in 46.1% of cases. Injury of the ICA and permanent artery occlusion were independent predictors of permanent neurological deficit related to the arterial injury. Arterial injury during anterior or middle cranial skull base microsurgery is a dramatic complication. Salvage techniques resulting in the occlusion of the injured artery have higher rates of death and of permanent neurological deficit. Non-occlusive techniques should be preferred, whenever feasible, to manage the injury.