Endovascular Management of Cavernous Internal Carotid Artery Pseudoaneurysms Following Transsphenoidal Surgery: A Report of Two Cases and Review of the Literature

Abstract

lateral quadrant of the pituitary fossa fenestration. This was controlled with Surgicel and surgical packs were inserted. Then, 3 days post-operatively, the patient was investigated with magnetic resonance angiography (MRA) which demonstrated a small left cavernous ICA pseudoaneurysm (Fig. 1a). Digital subtraction angiography (DSA) confirmed the presence of 4 × 3 mm aneurysm with a defined neck arising from the distal cavernous carotid just before the second genu (Fig. 1b). The aneurysm was selectively catheterised using an Echelon 10 microcatheter (Covidien, USA). A series of soft and ultrasoft coils (Boston, now Stryker, USA) were sequentially deployed into the pseudoaneurysm achieving complete occlusion (Fig. 2).Follow-up MRA performed 2 weeks later demonstrated a tiny neck remnant and repeat MRA at 6 weeks showed complete obliteration of the aneurysm. DSA at 4 months confirmed satisfactory occlusion (Fig. 3). The patient remains well 5 years after the surgery and intervention. Case 2A 43-year-old man with acromegaly underwent endoscopic transsphenoidal resection of a pituitary macroadenoma. Intra-operatively, brisk bleeding was encountered from a vessel arising from the medial aspect of left internal carotid artery at the junction of the dura and cavernous sinus. This was controlled with bipolar coagulation and surgical packs. On the second post-operative day the patient developed a left third nerve palsy and left retro-orbital discomfort. Computed tomography angiography (CTA) demonstrated a left parasellar haematoma but no vascular lesion. Formal DSA demonstrated mild narrowing of the cavernous ICA only (Fig. 4). On the fifth post-operative day the packs were removed and the patient was subsequently discharged. He represented Vascular complications of transsphenoidal surgery are rare [1] but are associated with significant morbidity and mortality [2]. The cavernous internal carotid artery (ICA) is most commonly injured [2]. Following initial control of haemorrhage, definitive treatment increasingly relies upon endovascular techniques aimed at preserving the parent vessel. We describe our experience managing two patients who developed pseudoaneurysms following transsphenoidal surgery. We employed unassisted coiling in one patient and coiling with flow diversion in the second. We have also reviewed the literature to explore other endovascular treatment options. Case 1A 41-year-old male presenting with a bitemporal hemianopia underwent microsurgical transsphenoidal resection of a non-functioning pituitary macroadenoma. Following dural opening, arterial bleeding was noted from the left supero-

ICAR: endoscopic skull‐base surgery

“…Postoperative vascular studies were mostly recommended for cases without sacrifice of the ICA or negative initial cerebral angiogram . There have been reports of delayed development of ICA pathology and these were usually reported within 1 month after initial injury, suggesting close follow‐up is warranted during the first month despite an initial negative angiogram . For cases where a follow‐up imaging modality was specified, a variety of modalities including angiography, CT angiography, and MR angiography have all been reported .…”

Endovascular coiling of recurrent trapped pseudoaneurysm of petrous ICA across the distal barrier: When the other way round is the only way around!

“…3 The causes other than the trauma can be skull base infections, malignancy, arteriopathy, radiation, iatrogenic, or a combination of these. [4][5][6] The myriad clinical presentations may also include otorrhagia, tinnitus, Horner's syndrome, and cranial nerve palsies. 7,8 Our patient did not have upfront clinical or imaging-based markers of trauma, neither the audio-visual abnormalities.…”

Recurrent epistaxis from inflamed granulated tissue and an associated pseudoaneurysm of the internal carotid artery: case report

“…Although there have been some previously reported cases of delayed pseudoaneurysm after TSA [ 6 – 8 ], it is very rare for pseudoaneurysm to develop and rupture more than 10 years after blood vessel damage (by TSA surgery), as in our case. Also, pseudoaneurysm is effectively treated with graft stent and coil embolization, and most of the time, they are completely obliterated [ 9 – 12 ]. The recurrence of treated pseudoaneurysm is not common; however, in our case, the previously treated pseudoaneurysm ruptured again 4 months after treatment.…”