Intracranial intrasellar kissing carotid arteries: case report

Filho, Arthur de Azambuja Pereira; Gobbato, Pedro Luís; Filho, Gustavo de Azambuja Pereira; Silva, Sandro Bertani da; Kraemer, Jorge Luiz

doi:10.1590/s0004-282x2007000200034

Cited by 22 publications

(9 citation statements)

References 19 publications

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“…4,9,10 Furthermore, “kissing” carotid arteries have been reported rarely to occur, and require additional consideration prior to selecting a transsphenoidal approach for sellar or suprasellar lesions. 8,9 In this series, the narrowest distance between parasellar ICAs noted in a patient undergoing transsphenoidal surgery was 9.1 mm, and splaying of the ICAs was noted in patients with sellar lesions compared with normal subjects. This gradual splaying was also pronounced when comparing patients with larger (≥ 10 mm) versus smaller (< 10 mm) lesions (20.2 vs 16.8 mm, p < 0.0001).…”

Section: Discussionmentioning

confidence: 60%

The neurosurgical anatomy of the sphenoid sinus and sellar floor in endoscopic transsphenoidal surgery

Zada

Agarwalla

Mukundan³

et al. 2011

JNS

103

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Object A considerable degree of variability exists in the anatomy of the sphenoid sinus, sella turcica, and surrounding skull base structures. The authors aimed to characterize neuroimaging and intraoperative variations in the sagittal and coronal surgical anatomy of healthy controls and patients with sellar lesions. Methods Magnetic resonance imaging studies obtained in 100 healthy adults and 78 patients with sellar lesions were reviewed. The following measurements were made on midline sagittal images: sellar face, sellar prominence, sellar angle, tuberculum sellae angle, sellar-clival angle, length of planum sphenoidale, and length of clivus. The septal configuration of the sphenoid sinus was classified as either simple or complex, according to the number of septa, their symmetry, and their morphological features. The following measurements were made on coronal images: maximum width of the sphenoid sinus and sellar face, and the distance between the parasellar and midclivus internal carotid arteries. Neuroimaging results were correlated with intraoperative findings during endoscopic transsphenoidal surgery. Results Three sellar floor morphologies were defined in normal adults: prominent (sellar angle of < 90°) in 25%, curved (sellar angle 90–150°) in 63%, flat (sellar angle > 150°) in 11%, and no floor (conchal sphenoid) in 1%. In healthy adults, the following mean measurements were obtained: sellar face, 13.4 mm; sellar prominence, 3.0 mm; sellar angle, 112°; angle of tuberculum sellae, 112°; and sellar-clival angle, 117°. Compared with healthy adults, patients with sellar lesions were more likely to have prominent sellar types (43% vs 25%, p = 0.01), a more acute sellar angle (102° vs 112°, p = 0.03), a more prominent sellar floor (3.8 vs 3.0 mm, p < 0.005), and more acute tuberculum (105° vs 112°, p < 0.01) and sellar-clival (105° vs 117°, p < 0.003) angles. A flat sellar floor was more difficult to identify intraoperatively and more likely to require the use of a chisel or drill to expose (75% vs 25%, p = 0.01). A simple sphenoid sinus configuration (no septa, 1 vertical septum, or 2 symmetric vertical septa) was noted in 71% of studies, and the other 29% showed a complex configuration (2 or more asymmetrical septa, 3 or more septa of any kind, or the presence of a horizontal septum). Intraoperative correlation was more challenging in cases with complex sinus anatomy; the most reliable intraoperative midline markers were the vomer, superior sphenoid rostrum, and bilateral parasellar and clival carotid protuberances. Conclusions Preoperative assessment of neuroimaging studies is critical for characterizing the morphological characteristics of the sphenoid sinus, sellar floor, tuberculum sellae, and clivus. The flat sellar type identified in 11% of people) or a complex sphenoid sinus configuration (in 29% of people) may make intraoperative correlation substantially more challenging. An understanding of the regional anatomy and its variability can improve the safety and accuracy of transsphenoidal and ...

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Section: Discussionmentioning

confidence: 60%

The neurosurgical anatomy of the sphenoid sinus and sellar floor in endoscopic transsphenoidal surgery

Zada

Agarwalla

Mukundan³

et al. 2011

JNS

103

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“…The term “kissing carotids” describes elongated carotid arteries that touch at the midline, which is observed retropharyngeal or intrasphenoidal/intrasellar – Infraoptic origin of ACA : …”

Section: Classification Of Normal Variantsmentioning

confidence: 99%

“…The reporting of normal variants is very important for surgeons and interventional radiologists, as some of these variants have to be considered to avoid disastrous consequences during interventions. –Disastrous hemorrhage is a risk in the following cases: ○Transsphenoidal pituitary operations in cases with PTA or intrasellar kissing carotids ○Middle ear operation in cases of persistent stapedial artery and aberrant intratympanic ICA …”

Section: Significancementioning

confidence: 99%

Anomalies and Normal Variants of the Cerebral Arterial Supply: A Comprehensive Pictorial Review with a Proposed Workflow for Classification and Significance

Hakim

Gralla

Rozeik³

et al. 2017

Journal of Neuroimaging

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Cerebral arteries may exhibit a wide range of variation from normal anatomy, which can be incidentally discovered during imaging. Knowledge of such variants is crucial to differentiate them from pathologies, to understand the etiology of certain pathologies directly related to a vascular variant, and to depict the changes in collateral circulation in patients with certain variants. Detection of particular variants may lead to the discovery of other nonvascular or vascular anomalies, especially aneurysms, and may also affect planning of endovascular or neurosurgical interventions. In this review, we summarize the variants and anomalies of cerebral arteries seen on cross-sectional imaging classified by a morphological approach and categorize their significance from a clinical perspective. This structured review is intended to serve as a guide for daily use in clinical practice.

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“…[ 21 29 ] Among other relevant workup, standard preoperative planning of TSS includes review of the distinct anatomical characteristics of the individuals’ sellar and sphenoid region as well as the course of the internal carotid arteries. [ 4 28 ] Most often, physicians spend only seconds on the examination of printed MRI films to exclude the presence of “kissing” carotids; this coupled with any other eye-catching pathology on films, such as a pituitary macroadenoma, may draw the attention of radiologists away from subtle flow artifacts. Thus, there is some concern that an incidental aneurysm may be present within the sellar region and become the cause for catastrophic intraoperative complications.…”

Section: Discussionmentioning

confidence: 99%

“…[ 1 29 ] One of the preoperative considerations for TSS is an exclusion of “kissing internal carotid arteries: (ICA), a rare anatomical variant and absolute contraindication for TSS. [ 25 28 38 ] However, even in the absence of this vascular configuration, the rate of intraoperative arterial injuries remains significant. In different case series, it has been reported to be as high as 1.1%.…”

Section: Introductionmentioning

confidence: 99%

Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report

Khachatryan¹,

Khachatryan²,

Fanarjyan³

et al. 2018

Surg Neurol Int

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Background:Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications.Case Description:We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention.Conclusions:This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.

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Intracranial intrasellar kissing carotid arteries: case report

Cited by 22 publications

References 19 publications

The neurosurgical anatomy of the sphenoid sinus and sellar floor in endoscopic transsphenoidal surgery

The neurosurgical anatomy of the sphenoid sinus and sellar floor in endoscopic transsphenoidal surgery

Anomalies and Normal Variants of the Cerebral Arterial Supply: A Comprehensive Pictorial Review with a Proposed Workflow for Classification and Significance

Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report

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