Abstract
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.
Key words
internal carotid artery - pseudoaneurysm - sellar reconstruction - transsphenoidal
References
Management of pituitary adenomas and related lesions with emphasis on transsphenoidal
microsurgery . New York: Appleton Century Croft 1982: 329-346 Pituitary Surgery: A Modern Approach . Basel, Karger 2006: 256-278 Current Techniques in Operative Neurosurgery . New York: Grune & Stratton 1977: 161-172
Correspondence
rc9dd@virginia.edu
