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Rupture from Cavernous Internal Carotid Artery Pseudoaneurysm 11 Years After Transsphenoidal Surgery

 Tom Morrison

 Background: Bioabsorbable plates are frequently utilized in the repair of skull base defects following transsphenoidal operations. Traumatic intracranial   pseudoaneurysms are a rare complication of trans- sphenoidal surgery. To date, iatrogenic carotid pseu- doaneurysm associated with the use of an absorb- able plate has been reported once.   Results A 57-year-old man with a large nonfunctional pituitary macroadenoma underwent an endoscopic transsphenoidal operation with gross total resection.   An absorbable plate was placed extradurally to re- construct the sellar floor. He experienced delayed   repeated epistaxis, followed by a right middle cere- bral artery distribution embolic stroke. Computed to- morgraphy (CT) angiogram 6 weeks postoperatively   revealed a 6 × 4 mm pseudoaneurysm located on the medial wall of the right cavernous internal carotid   artery. Stent coiling was used to successfully obliter- ate the pseudoaneurysm, and the patient fully recov- ered.   Conclusion Delayed erosion of the carotid artery wall caused by a plate used to reconstruct the sellar floor may manifest with epistaxis or embolic stroke. The authors’ preference is to avoid insertion of a rigid plate for sellar floor reconstruction in the absence   of intraoperative cerebrospinal fluid (CSF) leaks, un- less it is required to buttress a large skull base defect.   Short-segment embolization with stent coiling is the   preferred treatment option for carotid pseudoaneu- rysms following transsphenoidal operations.   Keywords: cavernous, carotid, pseudoaneurysm, ar- tery   Introduction: The transsphenoidal approach is the most commonly utilized operation for the surgical   treatment of sellar lesions and is a relatively safe op- eration in experienced centers.1 Following resection   of pituitary adenomas and other sellar tumors, many surgeons utilize absorbable plates to reconstruct the bony sellar floor to serve as a buttress for the sellar contents and repair construct. Although usually safe, vascular injury in conjunction with insertion of rigid   plates following sellar tumor resection has been de- scribed once before.2   Common complications of transsphenoidal opera- tions include endocrine abnormalities and cerebro- spinal fluid (CSF) leaks.3 Vascular injury is a rare but   serious complication of transsphenoidal surgery en- countered in 0.8 to 1.1% of cases, with an associated   mortality of nearly 30%.4,5,6 The majority of vascu- lar injuries are identified at the time of surgery, usu- ally resulting from direct injury to the internal carotid   artery during resection of tumor within the cavern- ous sinus or upon opening of the dura, often result- ing in profuse arterial hemorrhage.6,7,8,9 Other de- scribed vascular complications include vasospasm,   carotid thrombosis, cavernous sinus thrombosis,   embolism, caroticocavernous fistula, or pseudoan- eurysm.2,3,7,8,10,11,12,13,14,15,16,17,18,19   Postoperative carotid pseudoaneurysm, though rare, represents a grave risk to the patient if unrecognized.   It may lead to delayed hemorrhagic or embolic com- plications when the patient is no longer in a moni- tored hospital setting. This case report highlights the   importance of rapid diagnosis and treatment of these   lesions. We present a rare case of delayed pseudo- aneurysm and embolic stroke following erosion of a   rigid plate into the cavernous internal carotid artery.   Case Report: A 57-year-old man with a nonfunction- al pituitary macroadenoma causing vision loss un- derwent a gross total, endoscopic transsphenoidal   resection (Fig. 1). The tumor was invading the right cavernous sinus wall. During the procedure to resect