We present a 65-year-old male with recurrent skull base chordoma. The patient had undergone several endoscopic skull base resections and radiation therapy due to multiple recurrence. Most recent MRI showed aggressive recurrence of the tumor invading the skull base, ethmoid sinus, cavernous sinus and right orbit. He underwent a radical transfacial, transmaxillary resection of the tumor and orbital content. During the procedure the ICA was injured. Immediate cerebral angiogram showed stenosis and possible dissection of the cavernous ICA but with adequate distal flow. The next day, the patient experienced progressive left hemiparesis. A repeat cerebral angiogram showed worsening of the stenosis with minimal distal flow. Endovascular therapy failed. The patient did not pass the balloon test occlusion. An urgent cerebral revascularization procedure was recommended. The patient underwent a high-flow ICA-MCA bypass with a radial artery graft. Intraoperative indocyanine green angiogram showed adequate patency of the bypass. The patient remained neurologically intact. A postoperative cerebral angiogram 24-48hrs after the procedure showed adequate cerebral blood flow. The arterial graft had a focal stenosis that required balloon angioplasty. Used with permission from Barrow Neurological Institute.
This video has been taken from Urgent Cerebral Revascularization Bypass Surgery for Iatrogenic Skull Base ICA Injury, an article appearing in a future issue of Neurosurgery. It was submitted by corresponding author Peter Nakaji, MD, from the Division of Neurological Surgery, Barrow Neurological Institute at St. Joseph’s Hospital and Medical Center in Phoenix, Arizona.
