Jia-Nan Li1
ZhongCheng Wen1
Jiajie He1Minghao Zhou1Jun Liu1Qingbo Liu1Fuyong Li2
Peng Cao1*Chunyong Yu1*
Guobiao Liang1*
- 1Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
- 2Third Department of Neurosurgery, Liaoning Provincial People’s Hospital, Shenyang, Liaoning, China
Internal carotid artery rupture during skull base surgery represents a rare yet catastrophic complication, with limited reports documented in the literature. In this article, we describe a case of ICA rupture encountered during supratentorial craniotomy for recurrent pituitary adenoma resection. The rupture was successfully managed through a novel microsurgical repair technique, achieving complete tumor resection. A 48-year-old female presented with a history of progressive visual impairment in both eyes for the past two years, 14 years after the initial pituitary adenoma resection. Reoperation was performed through the original pterional incision. During tumor dissection, sudden rupture of the right ICA occurred. Immediate cervical common carotid artery compression was applied, followed by microsurgical hemostasis using absorbable gelatin sponge and cottonoids. Temporary aneurysm clips were placed to achieve proximal flow control, allowing full exposure of the ICA rupture site. A small autologous muscle patch was used to cover the defect, and microsurgical repair was performed using a figure-of-eight suture technique. Complete hemostasis and total tumor resection were achieved. Postoperative digital subtraction angiography confirmed the patency of the ICA without stenosis, and the patient exhibited no neurological deficits postoperatively. This case combined the advantages of muscle tissue application and surgical suturing. The use of autologous muscle tissue promoted platelet aggregation, reducing tension at the rupture site and preventing further vascular tearing, while rapid suturing minimized blood loss. Additionally, the proficient collaboration and coordination with the anesthesiologist and surgical assistants were vital for controlling the intraoperative hemorrhage and ensuring prompt repair.
Introduction
Internal carotid artery (ICA) rupture during craniotomy is a rare and catastrophic surgical complication, with an incidence of approximately 1.62%–8% (1, 2). The management principles must balance immediate hemostasis and long-term vascular patency. Current techniques are diverse and evolving; requiring careful consideration of the injury location, rupture morphology, surgical field space, and the patient's ability to compensate with collateral circulation. This places high demands on the surgeon's timely judgment.
Some scholars have conducted systematic reviews on these complications, summarizing previous vascular repair techniques and proposing an algorithm for vascular injury repair. These techniques include direct vessel suturing, the use of biomaterials, and autologous tissue repair. Each technique has its unique advantages, but the drawbacks of these methods are also evident (2) (Table 1). This article presents a case of ICA rupture and emergency intraoperative repair during a craniotomy for recurrent pituitary adenoma resection, illustrating a novel vascular repair technique. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Additionally, this article reviews and summarizes recent literature on the repair of ICA ruptures during carotid artery surgery.
Table 1. The advantage and disadvantage of various techniques for repairing an ICA rupture.
Case description
A 48-year-old female presented with a history of progressive visual impairment in both eyes for the past two years, 14 years after the initial pituitary adenoma resection. The patient had previously undergone two pituitary adenoma resections via a pterional approach at another hospital, with postoperative pathology confirming a pituitary adenoma. Ophthalmologic examination revealed tubular vision in the right eye and temporal visual field defect in the left eye. Laboratory tests were within normal ranges. Endocrinological assessment demonstrated elevated growth hormone (17.894 ng/mL; normal range: 0.01–3.607 ng/mL). No significant medical or family history was noted. Contrast-enhanced CT showed a well-defined, round-shaped mass in the sellar and suprasellar regions with marked enhancement, measuring 3.7 × 3.8 × 4.4 cm. The mass displaced the Willis circle laterally, with the tumor partially encasing both internal carotid arteries, classified as Knosp grade 4 (Figure 1).
Figure 1. (A,B) preoperative imaging in another hospital in 2011; (C,D) postoperative imaging in another hospital in 2011; (E,F) preoperative imaging in another hospital in 2014; (G,H) postoperative imaging in another hospital in 2014; (I,J) preoperative imaging in our hospital; (K,L) original surgical incision.
The patient was positioned supine with slight leftward head rotation. A craniotomy was performed via the previous pterional incision. During tumor dissection, torrential hemorrhage occurred from the superomedial aspect of the right ICA C7 segment. Failed conventional hemostasis precipitated immediate hemodynamic collapse, prompting the anesthesiologist to initiate manual compression at the cervical common carotid artery. Under microscopic visualization, hemostatic agents were applied while dissecting the proximal ICA (C6 segment) for temporary clip placement. After achieving proximal flow control, the arterial defect was repaired using 6-0 Prolene suture (Ethicon) with figure-of-eight technique, augmented by an autologous muscle graft interposition. The size of the autologous muscle is about 5 × 2 mm and not crushed. The suture depth was full-thickness. Complete hemostasis was verified following 20-minute temporary occlusion. Temporary elevation of blood pressure was used to maintain intracranial perfusion and cerebral protection. Intraoperative transfusion totaled 1,100 mL (800 mL packed red blood cells, 300 mL autologous blood). Gross total tumor resection was achieved with preserved neurological functions. Postoperative DSA confirmed patency of the repaired vessel (Figure 2). The patient has not experienced any new clinical neurological deficits since the surgery, and aspirin was not given after operation. Due to metal implants of other surgery, the early postoperative MRI was not performed. The 6-months follow-up CTA showed that the ICA was patency and no pseudoaneurysm.
Figure 2. (A) compression hemostasis by hemostatic sponge and cotton pads; (B) separate and block the C6 segment of the internal carotid artery temporarily; (C) expose the rupture of the internal carotid artery; (D,E) muscle tissue is covered by the rupture of the internal carotid artery, and the rupture is repaired by micro-suturing; (F) temporary blockage removed and hemostasis achieved successfully; (G–I) postoperative CT and DSA. (J) 6-months follow-up CTA.
Discussion
ICA rupture occurs in up to 8% of skull base surgeries, yet reports on managing this complication remain scarce (3). Based on current evidence, scholars propose the following management protocol: After localizing the rupture site, blood pressure control should be considered depending on the hemorrhage volume and bleeding rate. If immediate hemostasis is achievable, select appropriate repair techniques based on defect morphology. If hemorrhage cannot be rapidly controlled, emergency ICA occlusion should be performed, followed by immediate angiography to evaluate collateral circulation and guide subsequent endovascular treatment or revascularization.
Among various vascular repair techniques, suturing remains the gold standard. Direct anastomosis or suturing under temporary occlusion clip assistance demands exceptional microsurgical skills and requires thorough evaluation of collateral circulation. Sekhar et al. employed temporary occlusion techniques with 8-0 needle sutures to directly repair carotid artery rupture sites. Among their four treated cases, two patients achieved favorable outcomes, two experienced mild disability, and postoperative angiography confirmed patency in all repaired arteries. Direct suturing of vascular defects, as the most immediate repair method, provides the most definitive repair outcome. When prolonged suturing time is required, it can be combined with temporary proximal and distal occlusion of the ICA. This technique is generally suitable for ICA injuries with well-defined defects and low wall tension. For complex injuries involving irregular defects, direct suturing becomes technically challenging and may risk iatrogenic injury to the ICA (4, 5). For arterial defects under high wall tension, thorough evaluation of collateral circulation is prerequisite. This necessitates adequate mobilization of the ICA through circumferential dissection, partial vessel transection to reduce defect tension, followed by temporary occlusion and defect repair (6). In this case, the vascular defect exhibited a well-defined morphology but was under significant tension, compounded by severe local tissue adhesion from multiple prior surgeries. Direct suturing carried risks of further vascular tearing. Therefore, following temporary proximal occlusion, the “muscle coverage with internal figure-of-eight suturing technique” was employed. The figure-of-eight suturing technique, originally designed for high-tension tissue closure (e.g., muscle or aponeurosis), leverages its capacity to manage high-tension defects. Autologous muscle was utilized to buffer tension and provide secure anchoring points for traction sutures. This approach not only mitigated the risk of iatrogenic tearing inherent to direct suturing but also capitalized on the adhesive properties, sterility, and tissue compatibility of autologous muscle (Figure 3).
Figure 3. (A–D) pattern diagram.
In addition to suturing techniques, sutureless approaches for managing carotid artery ruptures have been widely adopted with advancements in material science and interventional techniques. Requejo et al. employed α-cyanoacrylate n-butyl ester (NBCA) injection at the arterial rupture site for hemostasis. NBCA, a radiolucent permanent liquid embolic material, induces coagulation upon contact with blood and is extensively utilized in treating cerebral and spinal arteriovenous malformations and dural arteriovenous fistulas. By injecting NBCA into the ICA rupture site and the surrounding subarachnoid space, rapid hemostasis is achieved as the material solidifies and hardens upon blood contact. However, this method is not a long-term solution. Primarily, NBCA, as a chemical agent, may induce inflammatory vascular reactions through prolonged stimulation of the ICA, leading to vascular occlusion. This approach is only applicable to cases with partial vascular wall incisions and demonstrates limited efficacy for complete vascular wall lacerations (7). Van Der Veken J et al. applied autologous muscle tissue to occlude arterial ruptures, achieving hemostasis. Likely due to platelet aggregation mechanisms, autologous muscle adheres rapidly to bleeding points and effectively controls hemorrhage compared to hemostatic materials like gauze or cottonoid patties, making it suitable for managing high-flow, high-pressure arterial ruptures. Additionally, muscle offers advantages such as adhesiveness, sterility, flexibility, and easy intraoperative accessibility. However, prolonged pressure application and “overpacking” with muscle may lead to vascular occlusion, with intraoperative precision in controlling the degree of compression posing challenges (8). Romani et al., while clipping a cavernous sinus segment aneurysm of the ICA via the lateral supraorbital approach, encountered rupture of the aneurysm fundus during extradural removal of the anterior clinoid process using a rongeur. The ICA was repaired with a single-clip device, achieving good arterial repair with patent blood flow. The advantage of this method lies in shortening operative duration and reducing vascular occlusion time. This technique is currently recommended for endoscopic surgery, while its application in microsurgery requires further clinical investigation (7) 4. The method of wrapping damaged blood vessels with artificial synthetic patches [polytetrafluoroethylene [PTFE], polyester [Dacron], etc.] or autologous tissues (dura mater, blood vessels, or muscle) is widely employed (9, 10). It is commonly used to treat blood-blister-like aneurysms and for emergency management of intraoperative ICA injuries. The synthetic materials or autologous tissues are fixed in place with clips to encase the rupture site. The wrapping pressure should be sufficient to provide structural support to seal the defect, yet not excessive to avoid vascular stenosis and potential hemodynamic disturbances (11–14). Thoralf Sundt et al. developed the Sundt Clip Graft neurosurgical vascular clip to address intraoperative intracranial arterial laceration injuries and fusiform dissecting aneurysms. The inner surface of the clip is lined with Teflon, and when positioned over the vascular defect, its spring mechanism applies pressure to the synthetic graft, effectively sealing and repairing the defect (4, 7, 8). The clip is available in various sizes to accommodate intracranial arteries of different diameters: 5–6 mm clips are suitable for the ICA, while 2.5 mm clips are designed for the middle, anterior, and posterior cerebral arteries. The advantage of this technique lies in its ability to repair vascular damage while maintaining vascular patency and integrity, particularly suitable for arterial tears with irregular edges where direct suturing is challenging. However, its limitations include two aspects: Firstly, the bulky and cumbersome design may interfere with surrounding temporary occlusion clips in confined surgical fields, potentially obstructing the surgical view and complicating subsequent procedures. Secondly, vascular wall coverage might compromise perforating vessels (15, 16). Fairgrieve et al. successfully repaired an intraoperative injury of the petrous segment of the ICA using venous graft combined with bone cement (methyl methacrylate-styrene copolymer activated by methyl methacrylate) fixation. In this case report, the damaged site of the ICA was located within an inaccessible bony canal, rendering conventional repair methods nearly infeasible. By utilizing the plasticity of bone cement as a supportive overlay on the venous patch, successful repair was achieved. This method has relatively limited applicability but can be considered for ICA injuries within bony canals (17). The innovation of sutureless techniques reflects the clinical demand for rapid hemostasis. Technologies such as NBCA glue, muscle grafts, and Sundt Clip Graft vascular clips each present distinct advantages and disadvantages, requiring high case selectivity and being applicable only under specific circumstances.
Bipolar electrocautery has been utilized in the treatment of blood-blister-like aneurysms and unruptured microaneurysms (18, 19). In endoscopic surgery, it has also been successfully applied to manage iatrogenic carotid artery injuries (20). While its application in microsurgical procedures has not been reported, it may hold potential for addressing minor carotid artery breaches. The aneurysm clip remodeling technique for vascular reconstruction is theoretically feasible, but no reports have been documented regarding its application in treating iatrogenic carotid artery injuries during microsurgical skull base procedures. However, descriptions of aneurysm clip usage for ICA ruptures in endoscopic procedures have been reported (20, 21). Similar to its application in blood-blister-like aneurysm treatment, parent artery stenosis remains the most common complication (22). Occlusion of the ICA, as a salvage option, may be considered through coiling or permanent clipping to sacrifice the vessel if all aforementioned methods are unfeasible, provided that sufficient collateral circulation exists in the anterior communicating artery and/or posterior communicating artery (23–25). Revascularization techniques, being relatively complex procedures, require thorough preoperative preparation and are typically performed electively. Preoperative comprehensive evaluation of intraoperative carotid artery rupture risks should be conducted, with strict avoidance of their emergency application during surgery whenever possible (26–28). Endovascular interventional techniques, with advancements in neurointerventional and hybrid surgical procedures, theoretically represent an ideal method for repairing iatrogenic ICA injuries. Coverage of the rupture site can be achieved through deployment of covered stents, flow-diverting devices, or overlapping stent placement, thereby sealing the defect while maintaining patency of the parent vessel. A notable drawback lies in the requirement for antiplatelet therapy with stent utilization, which may elevate postoperative bleeding risks. The advent of hybrid operating rooms enables temporary flow arrest using balloon occlusion proximal to the vascular defect, thereby providing additional time for intraoperative vascular repair (29–33).
Conclusion
Reports of carotid artery injuries during craniotomy are rare, demanding exceptional intraoperative decision-making and technical proficiency from surgeons. The internal figure-of-eight suturing technique offers advantages in managing high-tension carotid artery ruptures, while muscle tissue coverage can provide anchoring points for sutures, preventing further damage to the defect. This approach may represent an optimized repair method for intraoperative carotid artery ruptures. Further development of novel hemostatic materials or techniques is anticipated.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.
Ethics statement
Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
J-NL: Writing – original draft. ZW: Software, Writing – review & editing. JH: Writing – review & editing, Investigation, Software. MZ: Writing – review & editing, Supervision. JL: Writing – review & editing, Supervision. QL: Writing – review & editing, Supervision. FL: Writing – review & editing, Validation. PC: Visualization, Validation, Writing – review & editing. CY: Validation, Supervision, Writing – review & editing. GL: Validation, Writing – review & editing, Visualization, Funding acquisition.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. This work was supported by the Liao Ning Talent Revitalization Program, XLYC2002109.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fsurg.2025.1673961/full#supplementary-material
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Keywords: recurrent pituitary adenoma, skull base surgery, internal carotid artery rupture, vascular repair, complication
Citation: Li J-N, Wen Z, He J, Zhou M, Liu J, Liu Q, Li F, Cao P, Yu C and Liang G (2025) A new method for repairing internal carotid artery rupture in skull base surgery: a case report and review of the literature. Front. Surg. 12:1673961. doi: 10.3389/fsurg.2025.1673961
Received: 28 August 2025; Revised: 13 November 2025;
Accepted: 17 November 2025;
Published: 27 November 2025.
Edited by:
Roberto Colasanti, Maurizio Bufalini Hospital, ItalyReviewed by:
Calvin Mak, Queen Elizabeth Hospital (QEH), Hong Kong SAR, ChinaZhaohui Shi, Institute of ENT and Shenzhen Key Laboratory of ENT, China
Zeran Yu, The Affiliated Hospital of Yunnan University, China
Copyright: © 2025 Li, Wen, He, Zhou, Liu, Liu, Li, Cao, Yu and Liang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Peng Cao, cGVuZ2NhbzUxOEAxNjMuY29t; Chunyong Yu, NjAxMDQzNzU5QHFxLmNvbQ==; Guobiao Liang, bGlhbmdndW9iaWFvNjcwOEAxNjMuY29t