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.

Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1-2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed.

No consensus exists regarding pulseless otherwise well-perfused hand in pediatric Gartland type III fractures. The purpose of this retrospective study was to describe our strategy and to determine the guidelines of therapeutic consensus.
METHODS: 404 children were treated for a type III supracondylar humeral fracture. Extension fractures-induced acute vascular injuries were noticed in 68 patients and nerve injuries were associated in 32 of them. The radial pulse was absent in all patients with two clinical situations at the initial presentation: well-perfused hand with \'pink and warm\' hand in 63 patients and ischemia with \'white and cold\' hand in five. Urgent closed reduction of the fracture and stabilization were performed in 63 patients with pink pulseless hand, and immediate surgical exploration in the five patients with ischemia.
RESULTS: 63 patients with vascular injury had posterolateral displacement and 5 had posteromedial displacement. Sixty-three of 68 patients had posterolateral displacement of whom 28 had concomitant median nerve injury and 4 had a deficit to both median and ulnar nerves. The palpable radial pulse was immediately restored in 42 patients and between few hours to eleven days later in eighteen. Three patients with ischemia after unsuccessful reduction required immediate surgical exploration revealing incarceration of the brachial artery at the fracture site. Release and decompression of the brachial artery restored a normal limb perfusion. The five patients with primary ischemia underwent immediate open exploration and vascular repair. One of them had a compartment syndrome and required anterior fasciotomy. The restoration of blood flow with palpable radial pulse was observed in all patients. Full spontaneous nerve recovery was observed in all patients. At an average follow-up of 8.4 years, all patients had normal circulatory status, including a palpable radial pulse.
CONCLUSIONS: This study highlighted the reliability of non invasive strategy with good outcomes. We recommend urgent closed reduction of fracture. Close observation and monitoring is mandatory if pulseless hand remains warm and well-perfused. If the patients develop blood circulation disturbances or compartment syndrome following closed reduction, immediate vascular exploration is recommend.