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Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 670-672

Endovascular stent-graft placement for an iatrogenic internal carotid artery pseudoaneurysm following transsphenoidal surgery


Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, School of Medicine, 88 Jiefang Road, Hangzhou 310 009, China

Date of Submission10-Sep-2012
Date of Decision02-Oct-2012
Date of Acceptance18-Nov-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Xiao Dong
Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, School of Medicine, 88 Jiefang Road, Hangzhou 310 009
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105220

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How to cite this article:
Dong X, Zhang Y, Zhang Jm, Yu J. Endovascular stent-graft placement for an iatrogenic internal carotid artery pseudoaneurysm following transsphenoidal surgery . Neurol India 2012;60:670-2

How to cite this URL:
Dong X, Zhang Y, Zhang Jm, Yu J. Endovascular stent-graft placement for an iatrogenic internal carotid artery pseudoaneurysm following transsphenoidal surgery . Neurol India [serial online] 2012 [cited 2019 Aug 18];60:670-2. Available from: http://www.neurologyindia.com/text.asp?2012/60/6/670/105220


Sir,

A 55-year-old woman presented to our facility with a month-old history of epistaxis. She underwent transsphenoidal operation for pituitary adenoma and follow-up radiation therapy for a residual tumor 6 years prior to the present admission at another facility. Magnetic resonance imaging (MRI) showed a round-like mass with a significantly enhanced signal on the right side of sella turcica [Figure 1]. Digital subtraction angiography (DSA) showed an irregular pseudo-aneurysm with a 3.2-mm neck located on the cavernous part of right internal carotid artery (ICA) [Figure 2]. A 4 ΄ 12 mm Jostent coronary stent-graft (Abbot Vascular Devices, the Netherland) was installed at the injured site of the ICA onto an assistant balloon. Repeat DSA confirmed the stent graft covering the pseudo-aneurysm and good blood flow in the stented area [Figure 3]. Patient was put on anticoagulant medication including clopidogrel for 6 weeks and aspirin for 6 months. She recovered rapidly without any neurological deficits and was discharged 4 days after the endovascular intervention.

Vascular injury including carotid-cavernous fistula or pseudo-aneurysm is rare during transsphenoidal surgery, with a reported incidence of 0.2-1.2%, and is one of the fatal complications if not treated immediately and appropriately. [1],[2] This complication is inevitable during transsphenoidal surgery in some difficult cases because of a narrow open window, aggressive attempt to remove the tumor, and rupture of tiny cavernous and medial sphenoidal paraclinoidal aneurysm, which sometimes may be an associated lesion of the pituitary adenoma. [2],[3] The tiny cavernous and medial sphenoidal paraclinoidal aneurysm sometimes associated with pituitary tumor [4],[5] may not be noticed by neurosurgeons preoperatively or may not even be revealed by preoperative MRI due to the tortuosity of the cavernous part of ICA and also due to the inherent limitation of MRI as compared with DSA in detecting aneurysms. Besides radiation therapy, other factors that increase the risk of carotid injuries during transsphenoidal surgery include invasive adenomas, history of transsphenoidal surgery, and long-term dopamine agonist therapy. [2]
Figure 1: Preoperative coronal MRI demonstrates that there is a round-like mass at the right side of sella turcica (a) Which shows high signal intensity on the enhanced MRI (b)

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Figure 2: Cerebral angiography shows an irregular pseudo-aneurysm at the cavernous part of the right internal carotid artery, both on digital subtraction angiography (a) and reconstructive imaging (b) The neck of the pseudo-aneurysm is approximately 3.2 mm in diameter

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Figure 3: Postoperative cerebral angiography demonstrates that the pseudo-aneurysm no longer exists at the previous part of ICA, confirming that the neck of the pseudo-aneurysm had been completely covered by the stent graft

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Total occlusion of injured ICA by balloon and coil is a widely used, effective, and a relatively low-risk treatment for this particular lesion. [6],[7] However, a balloon occlusion test (BOT) must be done to evaluate the patient's tolerance to ICA occlusion on one side. If cross-flow from the opposite hemisphere is demonstrated on the angiogram and no neurological defects during the test can be detected, one can safely proceed with the balloon occlusion of ICA. In spite of this, 5-20% of the patients who pass the BOT develop infarction after permanent occlusion of affected carotid artery. [8]

Within the past decade, endovascular stent graft placement has become a promising and widely used alternative method for managing ICA injury during transsphenoidal surgery. Unlike the occlusion of ICA, stenting can preserve the blood supply of the injured carotid artery. Young, et al.[9] proposed a practical management strategy for ICA injury during transsphenoidal surgery. In our patient, we decided to perform an endovascular stent graft placement as soon as the DSA demonstrated pseudo-aneurysm without opting for BOT. We believed that complete occlusion of ICA would put the patient at a high risk of cerebral ischemia in the future.

 
  References Top

1.Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: Result of a national survey, review of the literature and personal experience. Neurosurgery 1997;40:225-37.  Back to cited text no. 1
[PUBMED]    
2.Berker M, Aghayev K, Saatci I, Palaoðlu S, Onerci M. Overview of vascular complications of pituitary surgery with special emphasis on unexpected abnormality. Pituitary 2010;13:160-7.  Back to cited text no. 2
    
3.Suzuki H, Muramatsu M, Murao K, Kawaguchi K, Shimizu T. Pituitary apoplexy caused by ruptured internal carotid artery aneurysm. Stroke 2001;32:567-9.  Back to cited text no. 3
[PUBMED]    
4.Bulsara KR, Karavadia SS, Powers CJ, Paullus WC. Association between pituitary adenomas and intracranial aneurysms: An illustrative case and review of the literature. Neurol India 2007;55:410-2.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Pant B, Arita K, Kurisu K, Tominaga A, Eguchi K, Uozimi T. Incidence of intracranial aneurysm associated with pituitary adenoma. Neurosurg Rev 1997;20:13-7.  Back to cited text no. 5
    
6.Chen D, Concus AP, Halbach VV, Cheung SW. Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: Diagnosis and endovascular therapy. Laryngoscope 1998;108:326-31.  Back to cited text no. 6
[PUBMED]    
7.Kim SH, Shin YS, Yoon PH, Kim DI. Emergency endovascular treatment of internal carotid artery injury during a transsphenoidal approach for a pituitary tumor: Case report. Yonsei Med J 2002;43:119-22.  Back to cited text no. 7
[PUBMED]    
8.Standard SC, Ahuja A, Guterman LR, Chavis TD, Gibbons KJ, Barth AP, et al. Balloon test occlusion of the internal carotid artery with hypotensive challenge. Am J Neuroradiol 1995;16:1453-8.  Back to cited text no. 8
[PUBMED]    
9.Park YS, Jung JY, Ahn JY, Kim DJ, Kim SH. Emergency endovascular stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery. Surg Neurol 2009;72:741-6.  Back to cited text no. 9
[PUBMED]    


    Figures

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