Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

BACKGROUND: Injury to the internal carotid artery (ICA) is a potentially devastating complication of endoscopic endonasal surgery (EES) that as many as 20% of skull base surgeons will experience at least once during their careers. Managing these injuries is difficult given the small operative field and poor visibility created by high-flow hemorrhage, and, at present, there is no consensus regarding best practices.
OBJECTIVE: This study seeks to consolidate the practices and opinions of experienced skull base surgeons from high-volume tertiary care centers into a single consensus statement regarding the best practices for managing ICA injuries during EES.
METHODS: A panel of 23 skull base surgeons (15 neurosurgeons and 8 otolaryngologists) completed a 3-round Delphi survey that assessed experiences and opinions regarding various aspects of ICA injury management. Mean (SD) years since fellowship completion was 15.6 (8.1) and all but 3 surgeons had experienced an ICA injury at least once.
RESULTS: The final consensus statement included 36 guidelines all of which were grouped under 1 of 4 categories: 11 statements concerned preoperative management and equipment for high-risk patients; 14 statements concerned hemorrhage control; 4 statements concerned definitive management; 7 statements concerned pharmacologic treatment, blood pressure, and neurophysiologic monitoring.
CONCLUSIONS: There are numerous decisions that a surgeon must make when facing a carotid artery injury. In our estimation, many questions can be grouped under 1 of the 4 categories outlined in our consensus statement and can be addressed by these findings.

BACKGROUND The complications of fine-needle aspiration cytology (FNAC) are rare but can be challenging for performing physicians to diagnose and manage. This type of procedure is perceived as routine and devoid of substantial risks, but uncommon complications can occur and need to be addressed with careful workup. CASE REPORT A FNAC procedure for a young female patient with multiple thyroid nodules was requested by her general practitioner. After the FNAC thyroid procedure, a carotid wall hematoma was suspected and could not be excluded with ultrasound (US) alone. Thus, the patient underwent a computed tomography angiogram (CTA) that excluded blood extravasation from the carotid, confirming the suspicion of perivascular blood accumulation. As a precaution, the patient was hospitalized, with US follow-up; she was dismissed the day after her hospital admission with a diagnosis of a benign thyroid nodule in multinodular goiter according to SIAPEC-IAP classification. CONCLUSIONS This case highlights how a routine-perceived procedure such as FNAC could present a challenge to the performing physicians, pathologist, and radiologist, raising the suspicion of a severe complication that needs to be addressed with a readily available emergency service that may be accessible only within a central hospital-level organization. This case reinforces the point that more careful adherence to clinic-radiological guidelines is needed to avoid potentially inappropriate and harmful procedures. A review of the literature concerning guidelines for FNAC procedure, diagnostic classifications, and reported complications is provided as part of this case report.

Anaesthetists in the Defence Medical Services (DMS) are currently dealing with casualties who have an increased prevalence of injuries due to blast, fragmentation and gunshot wounds. Despite guidelines already existing for unanticipated difficult tracheal intubation these have been designed for a civilian population and might not be relevant for the anticipated difficult airway experienced in the deployed field hospital. In order to establish an overview of current practice, three methods of investigation were undertaken; a literature review, a survey of DMS Anaesthetists and a search of the UKJoint Theatre Trauma Database. Results are discussed in terms of anatomical site, bleeding in the airway, facial distortion, patient positioning and an anaesthetic approach. There are certain key principles that should be considered in all cases and these are considered. Potential pitfalls are discussed and our initial proposed guidelines for use in the deployed field hospital are presented.

BACKGROUND: Blunt injury to the carotid or vertebral vessels (blunt cerebrovascular injury [BCVI]) is diagnosed in approximately 1 of 1,000 (0.1%) patients hospitalized for trauma in the United States with the majority of these injuries diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%. With screening, the incidence rises to 1% of all blunt trauma patients and as high as 2.7% in patients with an Injury Severity Score of >or=16. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the screening, diagnosis, and treatment of BCVI.
METHODS: A computerized search of the National Library of Medicine/National Institute of Health, Medline database was performed using citations from 1965 to 2005 inclusive. Titles and abstracts were reviewed to determine relevance, and isolated case reports, small case series, editorials, letters to the editor, and review articles were eliminated. The bibliographies of the resulting full-text articles were searched for other relevant citations, and these were obtained as needed. These papers were reviewed based on the following questions: 1. What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI? 2. What is the appropriate modality for the screening and diagnosis of BCVI? 3. How should BCVI be treated? 4. If indicated, for how long should antithrombotic therapy be administered? 5. How should one monitor the response to therapy?
RESULTS: One hundred seventy-nine articles were selected for review, and of these, 68 met inclusion criteria and are excerpted in the attached evidentiary table and used to make recommendations.
CONCLUSIONS: The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified (see ), screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (>or==8 slice) CT angiography may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population.

BACKGROUND: A surgical and anatomic approach to the skull base using the transmaxillary route is presented. This route is well-known and used for a long time for sinus conditions.
METHODS: This study was performed on injected cadavers. This study describes step by step this approach in microsurgical conditions following a vital lead: the infraorbital nerve.
RESULTS: Anatomical landmarks are located in order to avoid complications. These complications are on one hand, hemorrhages by vascular lesions and on the other, definitive nerve palsy.
CONCLUSIONS: Several skull base approaches exist, transfacial routes produce cosmetic damages. This route preserves the functional anatomy of the nose because it preserves the integrity of the lateral wall of the nasal cavity.

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BACKGROUND: Surgery in the parasellar and paranasal regions is technically challenging because of the complex anatomic relationships between the sphenoid sinus, cavernous sinus, optic nerve, and internal carotid artery. Normal anatomic variations and pathological changes can lead to disastrous outcomes including carotid artery injury.
METHODS: We present two cases of carotid injury managed at our institution. The first case involves an elective endoscopic biopsy of a clival tumor encasing a friable carotid artery. The second case features a patient transferred emergently to our medical center when brisk bleeding was encountered during functional endoscopic sinus surgery (FESS). Both carotid injuries were managed via balloon embolization with close interaction between otolaryngology and interventional radiology. We review pertinent anatomic and surgical considerations as a backdrop to a treatment algorithm for cavernous carotid hemorrhage secondary to FESS complication.
RESULTS: The treatment algorithm prevented mortality and minimized morbidity in the two cases considered.
CONCLUSIONS: Through rare, injury to the cavernous carotid during FESS can be managed successfully given efficient hemostasis and seamless cooperation among emergency room physicians, otolaryngologists, and interventional radiologists.

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BACKGROUND: Recent guidelines from the National Institute for Clinical Excellence (NICE) recommend the use of ultrasound guidance for central venous catheterization in children. This study prospectively examined the use of ultrasound guidance for central venous catheterization in children undergoing heart surgery.
METHODS: One hundred and twenty-four infants and children were randomized to either ultrasound-guided or traditional landmark-guided central venous catheterization.
RESULTS: Success rates were significantly greater in the landmark group compared with the ultrasound group (89.3% vs 78%, P<0.002), and arterial puncture rates were significantly lower in the landmark group (6.2% vs 11.9%, P<0.03). There was no significant difference between the two groups in the time taken to perform the catheterization.
CONCLUSIONS: These results are different from the published results on which the NICE guidelines were based; however, the evidence base in children is small. There is currently insufficient evidence to support the use of ultrasound guidance for central venous catheterization in children.