Open vascular treatment after internal carotid artery knife transection: illustrative case.

BACKGROUND: Although penetrating, nonmissile, traumatic cranial injuries with associated vascular injuries make up a small portion of all traumatic brain injuries, they can pose a unique challenge to the neurosurgeon. Recently, less invasive, endovascular treatment options have shown promise, but there remains a need for experience with open vascular treatment in certain circumstances. The authors describe the importance of careful surgical planning for open vascular repair of an internal carotid artery (ICA) transection injury after traumatic knife cranial penetration.

OBSERVATIONS: The authors present the case of a 21-year-old Brazilian male, victim of domestic assault by knife, which penetrated the temporal bone, anterior temporal lobe, cranial nerves, cavernous sinus, and right ICA. Digital subtraction angiography showed right ICA occlusion with associated thrombosis of cervical through clinoidal segments, with adequate collateral perfusion. The authors performed a pterional craniotomy for clip ligation of the clinoidal segment of the ICA, with safe removal of the knife and a favorable patient outcome. The authors describe a technical case illustration, accompanied by a surgical video and cadaver and anatomical illustration.

LESSONS: This case highlights the importance of detailed knowledge of cerebrovascular and skull base anatomy and preservation of complex open vascular neurosurgical techniques, especially in settings where endovascular treatment is not a feasible option. https://thejns.org/doi/10.3171/CASE2532.