Development of Internal Carotid Artery pseudoaneurysms (ICAp) after transsphenoidal surgery is extremely rare, occurring only in 0.4% of cases. Surgical treatment of ICAp poses a real challenge to the neurosurgeon as treatment may require parent vessel sacrifice or artery reconstruction with bypass grafting. Furthermore, surgical resolution of these lesions is rarely reported in the literature.
The internal carotid artery is prone to iatrogenic injury in transsphenoidal surgery due to its frequent involvement in pituitary adenomas. Intracranial pseudoaneurysms may be at high risk for rupture and increased morbidity and mortality. Here we present a case of a patient with an ICAp rupture two months after transsphenoidal surgery for a pituitary adenoma.
The coexistence of cerebral aneurysms and pituitary adenomas is rare, with an estimated incidence of approximately 3.6%. Intracranial aneurysms and pituitary adenomas have been reported by multiple authors in multiple studies, yet a clear association between them still does not exist. Cases of infectious and traumatic aneurysms in the context of pituitary tumors have been reported [
Traumatic intracranial aneurysms are rare and are classified in direct or indirect according to Burton et al. Direct trauma occurs during penetrating head injury or surgery, whereas indirect trauma results from blunt head injury [
Wilson and Dempsey reported one of the first traumatic aneurysms during a transsphenoidal surgery in their series of 250 pituitary adenoma surgeries [
A 39-year-old man presented to our institution after presenting with tonic-clonic seizures and neurological deterioration that required advanced airway management. Clinical history was relevant for a giant non-functioning pituitary adenoma which was treated via transsphenoidal surgery two months ago (
The patient underwent a simple CT which revealed Fisher IV subarachnoid hemorrhage and hydrocephalus (
Due to the severe cerebral edema, incipient malignant stroke and hydrocephalus, surgical management was chosen, as the need for decompressive craniectomy for patient´s survival was foreseen. First, a left precoronal ventriculostomy was placed to treat hydrocephalus and achieve brain relaxation for better surgical manipulation. A conventional right pterional craniectomy and surgical clipping of the aneurysm via subfrontal approach was performed (
Postoperative course took place in the Intensive Care Unit. Patient underwent tracheostomy and gastrostomy and weaning from ventilation was possible two weeks after surgery. Afterwards the patient received floor care and was discharged successfully.
Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to diagnose and treat. Iatrogenic pseudoaneurysm may occur after intracranial procedures such as tumor resection, stereotactic biopsy and transsphenoidal surgery. ICA pseudoaneurysms resulting from iatrogenic injuries during transsphenoidal surgery (TSS) are not true aneurysms, as they lack a true, full-thickness wall and are covered only by a fragile connective tissue layer [
The reported incidence of ICA injuries during TSS for pituitary tumors ranges between 0.55 and 1.1% [
Pseudoaneurysms may result in complications such as subarachnoid hemorrhage, epistaxis, and carotid cavernous fistula with resultant death or permanent neurologic deficit [
Risk factor associated with vascular injury during transsphenoidal surgery includes anatomic variations of the sphenoid bones, an abnormally short distance between ICAs, ICA displacement by the lesion, tumor invasion of the cavernous sinus, tumor adhesion to the ICA, acromegaly with distortion of the local anatomy, and unusual tortuosities in the ICA. Previous surgery, previous external radiotherapy, chemoradiotherapy, or prior treatment with bromocriptine for pituitary tumors have also been reported [
Routine preoperative cerebral MRA is highly recommended because patients treated for pituitary adenoma are likely to develop intracranial arterial aneurysms as iatrogenic complications. Furthermore, in untreated patients, the incidence of coincidental cerebral aneurysm is higher than would be expected by chance alone. If excessive bleeding occurs during or after transsphenoidal surgery, even after successful intraoperative tamponade, immediate vascular imaging should be obtained to rule out vessel wall damage [
Various treatment strategies have been used in the management of pseudoaneurysms, including observation. Nevertheless, endovascular embolization is the treatment of choice and the choice of endovascular technique is based on the location of the pseudoaneurysm, vascular anatomy and patient’s clinical status. Treatment modalities include coiling, liquid embolization, stent assisted coiling, covered stent implantation and flow diverting stents [
Surgical intervention is mandatory when endovascular treatment has failed or when significant mass effect and edema is present in ruptured cerebral pseudoaneurysms [
Occurrence of subarachnoid hemorrhage months after transsphenoidal surgery is extremely rare and its surgical management is not well documented in medical literature.
Endovascular therapy is the treatment of choice when possible, as it has been the most studied therapy in these cases. Nevertheless, ruptured pseudoaneurysms that cause significant edema or mass effect and/or are located in distal intracranial branches have a much better prognosis when surgical treatment is chosen in this context. Furthermore, preoperative routine evaluation with MRA is imperative since the incidence of coincidental pituitary adenoma and cerebral aneurysm is higher than would be expected by chance alone.
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
(A) Preoperative cranial MRI in sagittal and coronal T1-weighted sections. (B) A giant sellar tumor consistent with pituitary adenoma with heterogeneous gadolinium enhancement. MRI, magnetic resonance imaging
(A) Preoperative cranial CT scans in axial sections demonstrate Fisher IV subarachnoid hemorrhage and hydrocephalus. (B) Sagittal view demonstrates an extensive anterior cerebral artery stroke that prompted surgical resolution of the case. CT, computed tomography
(A) Cerebral angiotomography with 3D reconstruction, demonstrating the right internal carotid artery pseudo aneurysm and the dome’s medial orientation (B) as well as its proximity to the sellar surgical region suggesting pseudoaneurysm.
(A) Surgical view through a pterional approach depicting the right internal carotid artery and the inter opticcarotid space, which harbors the pseudoaneurysm in its depth. (B) Successful clipping was achieved using an angled fenestrated clip.
(A) Postoperative cerebral angiotomography showing aneurysm exclusion (B) and adequate distal flow.