Neurosurgery has evolved from the use of large craniotomies to increasingly less invasive approaches associated with less surgical trauma.1 Endoscopic transsphenoidal pituitary surgery has advantages over the traditional approach, including less unnecessary sacrifice of surrounding structures, improved visualization, and shorter length of hospital stay.[2], [3], [4] With improvements in endoscopic equipment and techniques and increased understanding of the relevant endonasal anatomy, endoscopic endonasal surgery has become the standard for resection of pituitary tumors.5 However, internal carotid artery (ICA) injury is a potential complication.6 ICA injury is infrequent but challenging to manage and potentially fatal.[7], [8] Such an injury may result in other vascular complications such as stroke from ICA stenosis or occlusion, pseudoaneurysm, or carotid–cavernous fistula.9 Transsphenoidal surgeons should try to avoid ICA injury but also be prepared to manage it. This article analyzes our experience with ICA injury during endoscopic transsphenoidal pituitary surgery, presents associated risk factors, and proposes a management protocol.