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 i nternal 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 l igation, balloon occlusion, or revascularization. Methods: We present the management and outcomes of four consecutive patients, two with pse udoaneurysms and two with acute occlusions, after injury to the distal cervical/petrous ICA from gunshot wounds, Preoperative assessment det ermined intracranial collateral flow patterns and the patency of the d istal portion of the petrous ICA. Results: Two patients underwent cerv ical-to-petrous ICA vein bypass grafts without neurologic complication s, Both grafts remain patent without evidence of emboli at 2 years and 3 months, respectively, Both of the conservatively managed patients d ied, one from a massive cerebral infarction and the other from intrace rebral hemorrhage. Conclusions: These cases underscore the need for an aggressive approach to the assessment and management of patients with penetrating vascular skull-base injuries, Although the optimal treatm ent of remains controversial, when the goal is exclusion of the injure d portion of the carotid artery and revascularization, the cervical to petrous ICA vein bypass graft is a valuable management option that ca n reduce the potential morbidity and mortality from acute ischemic or delayed embolic or hemorrhagic complications, provide immediate restor ation of high flow, and allow good surgical access with minimal risk t o intracranial structures.