Internal carotid injury during transsphenoidal surgery

E. Two-surgeon endoscopic control with focused packing while activating massive haemorrhage and neuro-interventional rescue

The priorities are visualisation, temporising focal tamponade, haemodynamic resuscitation and rapid angiography for definitive vessel assessment and endovascular control; blind clipping or uncontrolled suction can worsen injury.

Why every option is right or wrong

A. Withdraw all instruments and leave the nose unpacked: Removing tamponade allows uncontrolled exsanguination and aspiration.

B. Blindly coagulate the bleeding point: Thermal injury or enlargement of a carotid defect can be catastrophic.

C. Complete tumour resection before haemostasis: The planned procedure must be abandoned for vascular rescue.

D. Pack both nasal cavities tightly without localisation and discharge: Packing is a bridge within an emergency pathway, not definitive treatment or grounds for discharge.

E. Two-surgeon endoscopic control with focused packing while activating massive haemorrhage and neuro-interventional rescue: The priorities are visualisation, temporising focal tamponade, haemodynamic resuscitation and rapid angiography for definitive vessel assessment and endovascular control; blind clipping or uncontrolled suction can worsen injury.

What if the scenario changed?

If the bleeding were low-pressure cavernous-sinus venous bleeding and the internal carotid artery were confirmed intact, controlled endoscopic haemostasis with haemostatic material and completion or abandonment according to stability would replace the arterial-injury rescue pathway.