Endonasal surgery high-risk carotid injury timeout checklist: implementation, institutional protocol and experience.

Publication Title

Acta neurochirurgica

Authors

Garni Barkhoudarian, Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA.Follow
Mehrdad Pahlevani, Pacific Neuroscience Institute, Providence Saint John's Health Center, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.Follow
Seshaan Ratnam, Pacific Neuroscience Institute, Providence Saint John's Health Center, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.Follow
Regin Jay Mallari, Pacific Neuroscience Institute, Providence Saint John's Health Center, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.Follow
Chester Griffiths, Pacific Neuroscience Institute, Providence Saint John's Health Center, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.Follow
Daniel F Kelly, Saint John's Cancer Institute, Providence Saint John's Health Center, Santa Monica, California, USA.Follow

Document Type

Article

Publication Date

11-15-2024

Keywords

california; pni; sjci; santa monica; Humans; Carotid Artery Injuries; Male; Female; Checklist; Middle Aged; Pituitary Neoplasms; Aged; Adult; Postoperative Complications; Intraoperative Complications

Abstract

OBJECTIVE: Carotid artery injury is a rare, but major complication of endonasal operations. The morbidity and mortality of such a complication can be mitigated by preparedness and a clear plan set in place to address the hemorrhage expeditiously. This study examines the implementation of such a carotid injury timeout checklist and demonstrates its effectiveness in a patient with possible arterial injury.

METHODS: A carotid injury timeout checklist was implemented for high risk endonasal procedures. The case selection was left to the surgeon, with guidelines including prior surgery, prior radiation, invasive tumors, and certain pathologies such as meningioma or chordoma. Factors affecting implementation were analyzed including tumor characteristics and patient history.

RESULTS: Over a 12-month period, 103 endonasal operations were performed since the carotid artery injury timeout checklist was implemented, with 21 (20.4%) having a carotid artery injury timeout performed. Tumor characteristics that were associated with performing this timeout included Knosp grade (for pituitary adenomas, p = 0.002), carotid artery encasement (p < 0.001), extended approach (p < 0.001), tumor size (p = 0.05) and diagnosis (p < 0.001). Re-operation and prior radiation were not factors for this cohort. The single carotid artery branch (hypertrophic vidian artery) injury that was sustained was easily and successfully managed, aided by preparation established via this protocol. The additional time necessary for this timeout to be performed was negligible with respect to the overall surgery length.

CONCLUSION: A carotid artery injury timeout can and should be successfully implemented for extended endonasal operations for pituitary and parasellar tumors with high risk factors including, but not limited to, carotid injury encasement, large tumor size and non-adenomatous diagnoses. A comprehensive plan for both intraoperative and perioperative management of the carotid injury is necessary to minimize the risk of morbidity and to deliver care expeditiously.

Area of Special Interest

Neurosciences (Brain & Spine)

Area of Special Interest

Cancer

Specialty/Research Institute

Oncology

Specialty/Research Institute

Neurosciences

Specialty/Research Institute

Surgery

DOI

10.1007/s00701-024-06340-3