Gunshot wounds of the internal carotid artery at the skull base: Management with vein bypass grafts and a review of the literature

Background: Penetrating trauma to the skull base and distal cervical internal carotid artery (ICA) can result in occlusion or pseudoaneurysm formation. The appropriate management strategy for these rare lesions is controversial and includes observation, anticoagulation, carotid ligation, baboon occlusion, or revascularization. Methods: We present the management and outcomes of four consecutive patients, two with pseudoaneurysms and two with acute occlusions, after injury to the distal cervical/petrous ICA from gunshot wounds. Preoperative assessment determined intracranial collateral flow patterns and the patency of the distal portion of the petrous ICA. Results: Two patients underwent cervical-to-petrous ICA vein bypass grafts without neurologic complications. Both grafts remain patent without evidence of emboli at 2 years and 3 months, respectively. Both of the conservatively managed patients died, one from a massive cerebral infarction and the other from intracerebral hemorrhage. Conclusions: These cases underscore the need for an aggressive approach to the assessment and management of patient with penetrating vascular skull-base injuries. Although the optimal treatment of remains controversial, when the goal is exclusion of the injured portion of the carotid artery and revascularization, the cervical to petrous ICA vein bypass graft is a valuable management option that can reduce the potential morbidity and mortality from acute ischemic or delayed embolic on hemorrhagic complications, provide immediate restoration on high flow, and allow good surgical access with minimal risk to intracranial structures.