The perioperative management of the petrous carotid artery in contemporary surgery of the skull base.

Optimal techniques for the preoperative assessment and intraoperative management of the petrous carotid artery remain undefined. While purposeful "avoidance" of this structure may result in partial tumor removal, limited exposure of the petrous carotid artery may lead to inadvertent injury with life-threatening neurovascular sequelae. Twenty-five cases are reported in which surgical manipulation of the petrous carotid artery was necessary to accomplish total tumor removal or gain operative exposure to the skull base. A standard diagnostic radiographic assessment consisted of high-resolution computed tomography, magnetic resonance imaging, and a 4-vessel angiography. Preoperative balloon occlusion of the involved internal carotid artery was performed in four patients. Surgical approaches used in this series were broadly classified as: infratemporal-anterolateral (14), pterional-infratemporal (6), or pterional-anterolateral (5). Intraoperative management of the carotid artery consisted of total decompression in 19 cases, decompression with mobilization in four patients, and resection in two instances. Major neurovascular complications included one stroke and death caused by arterial occlusion, one stroke and death caused by arterial spasm, one stroke caused by brain edema, and one death related to a postoperative carotid hemorrhage. Other nonvascular complications included brain swelling, cranial nerve palsies, dysphagia, ataxia, cerebrospinal fluid fistulae, flap necrosis with wound infection, and pneumocephalus. Invasive and noninvasive methods are outlined for the preoperative assessment of the petrous carotid in cases of advanced skull base disease and intraoperative management options are detailed.