© Georg Thieme Verlag KG Stuttgart · New York
Bilateral Intracavernous Carotid Artery Pseudoaneurysms as a Result of Sellar Reconstruction during the Transsphenoidal Resection of a Pituitary Macroadenoma: Case Report
26 February 2009 (online)
Objective and Importance: Transsphenoidal surgery is considered to be a safe, relatively low risk procedure for the resection of pituitary lesions. Although rare, injury to the internal carotid artery is a potentially devastating complication associated with the transsphenoidal approach. The authors report a unique case in which the patient developed mirror pseudoaneurysms of the cavernous carotid arteries after an apparently uneventful transsphenoidal procedure, a complication attributed to the reconstruction of the sellar floor.
Clinical Presentation: The patient is a 55-year-old gentleman who presented to the emergency room with severe epistaxis nearly 4 weeks after undergoing an uncomplicated transsphenoidal resection of a pituitary adenoma. An emergency cerebral angiogram was performed which demonstrated bilateral cavernous carotid artery pseudoaneurysms, a complication attributed to the placement of a synthetic implant in the sellar floor. While on the angiography table, the patient again developed massive epistaxis, with enlargement of the left-sided pseudoaneurysm from 3.4×2.5×2.1 mm to 4.5×3.7×3 mm.
Intervention: The left cavernous carotid artery was occluded using 8 coils. The right-sided pseudoaneurysm was not treated at the time of the angiogram, and was managed conservatively. The patient subsequently developed an expressive aphasia, with an MRI revealing multiple areas of diffusion-weighted abnormalities. Within several days the patient's speech returned to normal, and he was discharged home eleven days after presenting to the emergency room. Follow-up imaging 6 weeks later showed complete obliteration of the left cavernous carotid artery with distal reconstitution, and a decrease in size of the right-sided pseudoaneurysm.
Conclusion: While considered to be a relatively safe procedure, the transsphenoidal approach for resection of pituitary lesions is not without risks. Injury to the internal carotid artery is arguably the most catastrophic complication seen with pituitary surgery. Although it typically occurs during the dural opening, or during tumor removal, this case illustrates that the neurosurgeon must be conscious of this risk throughout every aspect of the case. For cases when sellar reconstruction is performed, specific attention should be paid to ensuring that an appropriately sized graft is used.
internal carotid artery - pseudoaneurysm - sellar reconstruction - transsphenoidal
- 1 Wilson CB, Dempsey LC. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg. 1978; 48 13-22
- 2 Ciric I, Ragin A, Baumgartner C. et al . Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997; 40 225-236 , discussion 236–227
- 3 Barzaghi LR, Losa M, Giovanelli M. et al . Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre. Acta Neurochir (Wien). 2007; 149 877-885
- 4 Laws
ER, Kern EB. Complications of transsphenoidal surgery. In: Laws ER Jr, Randall RV, Kern EB, Abboud CF, eds.
Management of pituitary adenomas and related lesions with emphasis on transsphenoidal microsurgery. New York: Appleton Century Croft 1982: 329-346
- 5 Laws Jr ER. Vascular complications of transsphenoidal surgery. Pituitary. 1999; 2 163-170
- 6 Cappabianca P, Cavallo LM, Colao A. et al . Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg. 2002; 97 293-298
- 7 Fiorella D, Albuquerque FC, Deshmukh VR. et al . Endovascular reconstruction with the Neuroform stent as monotherapy for the treatment of uncoilable intradural pseudoaneurysms. Neurosurgery. 2006; 59 291-300 , discussion 291–300
- 8 Cappabianca P, Alfieri A, Colao A. et al . Endoscopic endonasal transsphenoidal surgery in recurrent and residual pituitary adenomas: technical note. Minim Invas Neurosurg. 2000; 43 38-43
- 9 Cavallo LM, Briganti F, Cappabianca P. et al . Hemorrhagic vascular complications of endoscopic transsphenoidal surgery. Minim Invas Neurosurg. 2004; 47 145-150
- 10 Reddy K, Lesiuk H, West M. et al . False aneurysm of the cavernous carotid artery: a complication of transsphenoidal surgery. Surg Neurol. 1990; 33 142-145
- 11 Ciceri EF, Regna-Gladin C, Erbetta A. et al . Iatrogenic intracranial pseudoaneurysms: neuroradiological and therapeutical considerations, including endovascular options. Neurol Sci. 2006; 27 317-322
- 12 Vanninen RL, Manninen HI, Rinne J. Intrasellar latrogenic carotid pseudoaneurysm: endovascular treatment with a polytetrafluoroethylene-covered stent. Cardiovasc Intervent Radiol. 2003; 26 298-301
- 13 Oskouian R, Kelly DF, Laws
ER. Vascular injury and transsphenoidal surgery. In: Laws ER J, Sheehan JP, ed.
Pituitary Surgery: A Modern Approach. Basel, Karger 2006: 256-278
- 14 Raymond J, Hardy J, Czepko R. et al . Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol. 1997; 18 655-665
- 15 Cappabianca P, Briganti F, Cavallo LM. et al . Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach. Acta Neurochir (Wien). 2001; 143 95-96
- 16 Kadyrov NA, Friedman JA, Nichols DA. et al . Endovascular treatment of an internal carotid artery pseudoaneurysm following transsphenoidal surgery. Case report. J Neurosurg. 2002; 96 624-627
- 17 Ahuja A, Guterman LR, Hopkins LN. Carotid cavernous fistula and false aneurysm of the cavernous carotid artery: complications of transsphenoidal surgery. Neurosurgery. 1992; 31 774-778 , discussion 778–779
- 18 Cabezudo JM, Carrillo R, Vaquero J. et al . Intracavernous aneurysm of the carotid artery following transsphenoidal surgery. Case report. J Neurosurg. 1981; 54 118-121
- 19 Dolenc VV, Lipovsek M, Slokan S. Traumatic aneurysm and carotid-cavernous fistula following transsphenoidal approach to a pituitary adenoma: treatment by transcranial operation. Br J Neurosurg. 1999; 13 185-188
- 20 Mortini P, Losa M, Barzaghi R. et al . Results of transsphenoidal surgery in a large series of patients with pituitary adenoma. Neurosurgery. 2005; 56 1222-1233 , discussion 1233
- 21 Dusick JR , Esposito F, Malkasian D. et al . Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery. 2007; 60 322-328 , discussion 328–329
- 22 Cappabianca P, Cavallo LM, Esposito F. et al . Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Neurosurgery. 2002; 51 1365-1371 , discussion 1371–1362
- 23 Kabuto M, Kubota T, Kobayashi H. et al . Long-term evaluation of reconstruction of the sellar floor with a silicone plate in transsphenoidal surgery. J Neurosurg. 1998; 88 949-953
- 24 Kobayashi S, Sugita K, Matsuo K. et al . Reconstruction of the sellar floor during transsphenoidal operations using alumina ceramic. Surg Neurol. 1981; 15 196-197
- 25 Spaziante R, Divitiis E de, Cappabianca P. Reconstruction of the pituitary fossa in transsphenoidal surgery: an experience of 140 cases. Neurosurgery. 1985; 17 453-458
- 26 Kaptain GJ, Vincent DA, Laws Jr ER. Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants. Neurosurgery. 2001; 48 232-233 , discussion 233–234
- 27 Laws
ER. Transsphenoidal approach to lesions in and about the sella turcica: Operative technique. In: Schmidek HH SW, ed.
Current Techniques in Operative Neurosurgery. New York: Grune & Stratton 1977: 161-172
- 28 Charbel FT, Gonzales-Portillo G, Hoffman W. et al . Distal internal carotid artery pseudoaneurysms: technique and pitfalls of surgical management: two technical case reports. Neurosurgery. 1999; 45 643-648 , discussion 648–649
R. W. Crowley, MD
Department of Neurosurgery
UVA Health Sciences Center
Phone: +1/434/982 32 44
Fax: +1/434/243 29 54