Retained transcranial knife blade with transection of the internal carotid artery treated by staged endovascular and surgical therapy: Technical case report

BACKGROUND AND IMPORTANCE: We describe the use of proximal and distal endovascular coil embolization of the internal carotid artery followed by operative removal of a retained foreign object transecting the petrocavernous portion of the internal carotid artery. CLINICAL PRESENTATION: A 20-year-old man sustained a stab wound to the left temporal skull and presented with a retained knife blade. He reported a headache at presentation, but remained neurologically intact with a Glasgow Coma Scale of 15. Computed tomography imaging and subsequent angiography confirmed complete transection of the petrocavernous segment of the left internal carotid artery with effective tamponade by the knife blade in situ and satisfactory collateral flow across the Circle of Willis. Coil embolization of the left internal carotid artery was performed. Retrograde embolization of the petrocavernous internal carotid segment distal to the injury was performed via vertebral and posterior communicating artery access. Ante-grade embolization of the internal carotid artery proximal to the injury was completed and the patient was transferred to the operating room for craniectomy and foreign body extraction. Postoperative computed tomography angiography revealed no parenchymal hemorrhage, mass effect, or midline shift, and successful embolization of the internal carotid artery. At 6-week follow-up, the patient remained neurologically intact with no infectious or vascular complications. CONCLUSION: Staged endovascular and surgical therapy provides complete assessment and effective control of damaged vessels when retained intracranial foreign bodies are present. Given the high risk of vascular injury with retained transcranial foreign bodies, this strategy should be considered a safe approach for these challenging cases.