Urgent Intracranial Carotid Artery Decompression after Penetrating Head Injury
A 46-year-old man suffered a penetrating injury to the face from the broken blade of an industrial grinder while doing demolition work. He was transferred to the emergency room with fading mental awareness. The facial laceration was 15 cm in length from nose to right cheek (). A piece of the broken blade was observed in the deep portion of the facial wound. Facial bone CTs revealed a blade fragment in the anterior skull base from his nose to the dorsum sellae area (). Brain CTs demonstrated the involvement of the right temporal lobe, cavernous sinus, paraclinoid segment of the carotid artery (). Also there were traumatic subarachnoid hemorrhage, pneumocephalus without apparent low attenuation area of the right ICA (). Raw data from CT angiography revealed non-visualization of the right carotid artery while left carotid artery density was visible (). The paraclinoid area was occupied by the foreign body, suggesting ICA encroachment. Delayed time to peak of the right side was noticed on perfusion CT suggesting right carotid artery occlusion (). Progressive left side weakness developed after admission. Because of the patient's critical condition, we needed prompt management to restore blood flow without digital substraction angiography (DSA). Emergency skull base surgery was planned to unblock the cavernous sinus. And then we considered extracranial to intracranial high flow arterial bypass in case of flow decrement on the right ICA. Conventional craniotomy was performed on the right pterional area. After extradural removal of the anterior clinoid process, micro-Doppler revealed restoration of carotid flow to the paraclinoid segment (). Intradural inspection revealed displacement of the carotid artery due to the foreign body (). The carotid artery was found to be impinged between the foreign body and anterior clinoid process, as expected from the CT angiography image (). Microscopic investigation of the intracranial lesion revealed disruption of the pituitary stalk and fracture displacement of the dorsum sellae, but not open injury to the intracranial ICA. A flow meter revealed 40 mL/min flow to the paraclinoid ICA (). The planned bypass surgery was cancelled. Eight hours elapsed from occlusion to reopening. Surgical glue was injected into the cavernous sinus to restore hemostasis. The broken blade was extracted from the face () without no massive bleeding. The wound was irrigated and the bone defect was closed with artificial dura and the temporalis muscle. Lumbar puncture and draining was performed to prevent leakage of cerebrospinal fluid (CSF) from the wound. And then, the surgery for Lefort I fracture and soft tissue defect on the right cheek was done by plastic surgeon. The patient recovered from his left side weakness and additional surgery to treat an infected wound was successful. The patient suffered from severe brain swelling due to ischemic brain injury on the lesion side but recovered fully after barbiturate coma therapy with the ICP monitoring for a week. He was treated with hormone replacement, including hydrocortisone and T4, due to the pitutitary stalk injury. Complete recanalization of the right ICA was confirmed by the DSA which was performed at 2 months after surgery (). He was discharged three months after admission without any motor weakness.