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Preoperative occlusion of ICA for complete excision of tumor

Case - 1: Middle aged lady presented with a large vascular tumour in the skull base encasing the internal carotid artery. For the complete  removal of the tumour, surgeon wanted to remove it along with the encased segment of internal carotid artery. In such situation, it is possible to do that provided that side of the brain gets adequate suplly from opposite side. It is tested during the angiogram by balloon occlusion test. For excision of internal carotid artery, surgeon prefers to get the artery occluded above the level of the tumor to get good control of back bleeding. 
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Left carotid angiogram showing large glomus tumour which is extending into the neck and causing encasement of left internal carotid artery at skull base.
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Test occlusion of left carotid artery with balloon was done to see the adequacy of cross circulation through circle of willis.

Balloon is shown by arrow which is occluding the artery.

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Left internal carotid angiogram -encasement of ICA at skull base. The encased segment has become irregularly narrow.
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Right carotid angiogram has been performed while left carotid artery is occluded to check if right internal carotid artery is supplying left side of the brain adequately or not.

Here we see that right internal carotid artery is supplying the left side of the brain adequately in absence of supply from left internal carotid artery.

 

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Microcatheter is seen  in Left ICA  through which coils were deployed to occlude left ICA above the level of tumour. This procedure is performed to facilitate the surgery in two ways.(1) Vascularity of the tumour reduces significantly if not totally due to preoperative embolization (2) It is difficult for a surgeon to occlude the artery at skull base as it is not accessible and to do it intracranially increases one step of surgery requring opening of skull and handling of brain.
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Coil in left ICA
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Coils in left ICA have occluded the artery. Point of occlusion is shown by the arrow.

 

Case - 2: Young lady with large nasopharyngeal cancer encasing the right internal carotid artery.

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Tumor in the right  side of skullbase - axial CT scan
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Tumor in the right  side of skullbase - coronal CT scan
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After checking the adequacy of cross circulation through circle of Willis , occlusion of right internal carotid artery was performed above the level of tumour (as shown by arrow in cavernous segment with balloon)
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Post embolization  angiogram shows no flow through right internal carotid artery.

 

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