Objectives To summarize the experience of perioperative anesthesia management in patients with internal carotid artery rupture undergoing transnasal sphenoidal approach neurosurgery. Methods We collected the medical records of patients with internal carotid artery rupture undergoing transnasal sphenoidal approach neurosurgery from January 1, 2020 to December 30, 2023 in Beijing Tiantan Hospital. Demographic, perioperative, and postoperative data were retrospectively analyzed. Results Internal carotid artery rupture occurred in 7 patients. The mean baseline blood pressure was 154/86mmHg (minimum 120/60 mmHg, maximum 200/110 mmHg), the mean blood pressure after internal carotid artery rupture was 103/58mmHg (minimum 160/70mmHg, maximum 50/30mmHg). The variance of systolic blood pressure was 26.2% (17.8%, 38.4%). Six patients recovered and were discharged, one patient died after being discharged. Conclusions Patients with internal carotid artery rupture during transnasal sphenoidal approach neurosurgery suffered higher risk of severe disability and death. The anesthesiologists should be vigilant. Detailed preoperative assessment and comprehensive intraoperative monitoring are very important. The priority of the anesthesia management is to actively supplement blood volume, maintain circulation stability, reduce instantaneous blood loss and maintain internal environment stability.