Skull Base Approach to Carotid Artery Lesions: Technique, Indications, and Outcomes

Abstract

Operative approaches to lesions of the carotid artery at the skull base are challenging and place multiple cranial nerves at risk. Endovascular approaches have enhanced the accessibility of this area, but some lesions are not amenable to endovascular management. Herein we describe a preauricular approach utilizing anterior dislocation of the temporomandibular joint with microscopic drillout of the medial glenoid and eustachian tube to identify and skeletonize the carotid artery in the foramen lacerum. Reviewing our experience with a direct open approach to the distal carotid artery revealed 10 patients from our institution. Nine of the patients presented with aneurysm, six spontaneous and three following blunt trauma, and one patient presented with carotid artery rupture after penetrating trauma. Eight patients underwent reverse saphenous vein grafting and two had resection with primary reanastomosis. Two of the patients presented with cranial nerve (CN) X deficits, and these persisted following surgery. Three of the eight patients without CN deficits preoperatively experienced postoperative deficits. One patient also suffered a mild CVA but had no permanent sequelae. Thus overall 5 (50%) of the 10 patients suffered no neurologic deficits and 7 (70%) suffered no new neurologic deficits as a result of surgery. One patient had persistent temporomandibular joint dysfunction. All patients had long-term patency of the graft or anastomosis, and no new neurologic symptoms were reported with a mean follow-up of 55 months. Open approaches to the carotid artery at the skull base are feasible and with careful anatomic dissection can be carried out with minimal morbidity in most cases. We present full details and images of the operative approach.