Abstract
BACKGROUND: Arterial injuries are among the most dangerous complications of endoscopic endonasal skull base surgery (EESBS), posing a risk of massive hemorrhage and requiring immediate management. Although uncommon, such events can be life-threatening. This report describes the first documented case of using a transcranial approach to control an arterial injury sustained during EESBS, with hemostasis achieved via bipolar diathermy. OBSERVATIONS: During endoscopic resection of a tuberculum sellae meningioma, profuse bleeding from the right frontopolar artery occurred. Initial control measures-large bore suction, hemostatic agents, and muscle packing-proved insufficient through the endonasal route. As an endovascular option was not available, a left pterional craniotomy was performed, where the lacerated artery was successfully coagulated. Simultaneously, endoscopic packing was maintained to limit ongoing hemorrhage. The procedure lasted 10 hours 40 minutes, with a total blood loss of 5 L. The patient survived the event but experienced worsened vision. LESSONS: This case underscores the severity of arterial injuries during EESBS and the importance of prompt, adaptable management. Core mitigation strategies include early recognition, precise localization of the bleeding vessel, aggressive packing, and timely conversion to an alternative approach, such as a transcranial route, when endonasal control fails. https://thejns.org/doi/10.3171/CASE25281.