Cerebral revascularization and carotid artery resection at the skull base for treatment of advanced head and neck malignancies

Clinical article

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Object

Resection of cancer and the involved artery in the neck has been applied with some success, but the indications for such an aggressive approach at the skull base are less well defined. The authors therefore evaluated the outcomes of advanced skull base malignancies in patients who were treated with bypass and resection of the internal carotid artery (ICA).

Methods

The authors retrospectively reviewed the charts of all patients with advanced head and neck cancers who underwent ICA sacrifice with revascularization in which an extracranial-intracranial bypass was used between 1995 and 2010 at the Barrow Neurological Institute.

Results

Eighteen patients (11 male and 7 female patients; mean age 46 years, range 7–69 years) were identified. There were 4 sarcomas and 14 carcinomas that involved the ICA at the skull base. All patients underwent ICA sacrifice with revascularization. One patient died of a stroke after revascularization. A second patient died of the effects of a fistula between the oral and cranial cavities (surgery-related mortality rate 11.1%). Eight months after the operation, 1 patient developed occlusion of the bypass and died. Complications associated with the bypass surgery included 1 case of subdural hematoma (SDH) with blindness, 1 case of status epilepticus, and 1 case of asymptomatic bypass occlusion (bypass-related morbidity 16.7%). Complications associated with tumor resection included 3 cases of CSF leakage requiring repair and shunting, 1 case of hydrocephalus requiring shunting, 1 case of SDH, and 1 case of contralateral ICA injury requiring a bypass (tumor resection morbidity rate 33.3%). In 1 patient treated with adjuvant therapy before surgery, the authors identified only a radiation effect and no tumor on resection. In a second patient the bypass was occluded, and her tumor was not resected. The other 16 patients underwent gross-total resection of their tumor. Excluding the surgery-related deaths, the mean and median lengths of survival in this series were 13.2 and 8.3 months, respectively (range 1.5–48 months). Including the surgery-related deaths, the mean and median lengths of survival were 11.8 and 8 months, respectively (range 17 days–48 months). At last follow-up all patients had died of cancer or cancer-related causes.

Conclusions

Despite maximal surgical intervention, including ICA sacrifice at the skull base with revascularization, patient survival was dismal, and the complication rate was significant. The authors no longer advocate such an aggressive approach in this patient population. On rare occasions, however, such an approach may be considered for low-grade malignancies.

Abbreviations used in this paper:CA = carotid artery; ICA = internal CA; MCA = middle cerebral artery; RAG = radial artery graft; SCC = squamous cell carcinoma; SDH = subdural hematoma; STA = superficial temporal artery; SVG = saphenous vein graft.

Article Information

Address correspondence to: Iman Feiz-Erfan, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, Arizona 85013. email: Neuropub@dignityhealth.org.

Please include this information when citing this paper: published online October 19, 2012; DOI: 10.3171/2012.9.JNS12332.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 2. Imaging studies obtained in a 66-year-old woman. Axial T1-weighted MRI studies without (A) and with (B) contrast demonstrating a recurrent SCC on the left side encasing the cavernous ICA with extension into the orbit. The lesion infiltrates the left ICA and cavernous sinus (arrow). Note the absence of flow void in the left cavernous ICA. These images were obtained after clip occlusion of the left ICA in the neck and supraclinoid region. C: Angiogram demonstrating the ICA-MCA with saphenous vein bypass before the tumor was resected. D: Axial T1-weighted MR image obtained after tumor resection. The skull base has been reconstructed with free tissue transfer by using a rectus abdominus muscle flap. Reprinted with permission from Feiz-Erfan et al.: Neurosurg Focus 14(3):e6, 2003.

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    Illustration of a bonnet bypass in a case of tumor involving the CA in the infratemporal fossa. Used with permission from Barrow Neurological Institute.

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    Angiogram demonstrating a patent bonnet bypass.

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    Photomicrographs of tumor sections demonstrating invasion of the CA wall by tumor cells (left) and cellular nests within the adventitia (right). H & E, original magnification ×40 (left) and ×100 (right).

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