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Delayed cavernous carotid artery pseudoaneurysm caused by absorbable plate following transsphenoidal surgery: case report and review of the literature.

Tuchman A, Khalessi AA, Attenello FJ, Amar AP, Zada G - J Neurol Surg Rep (2013)

Bottom Line: To date, iatrogenic carotid pseudoaneurysm associated with the use of an absorbable plate has been reported once.The authors' preference is to avoid insertion of a rigid plate for sellar floor reconstruction in the absence of intraoperative cerebrospinal fluid (CSF) leaks, unless it is required to buttress a large skull base defect.Short-segment embolization with stent coiling is the preferred treatment option for carotid pseudoaneurysms following transsphenoidal operations.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

ABSTRACT
Background Bioabsorbable plates are frequently utilized in the repair of skull base defects following transsphenoidal operations. Traumatic intracranial pseudoaneurysms are a rare complication of transsphenoidal surgery. To date, iatrogenic carotid pseudoaneurysm associated with the use of an absorbable plate has been reported once. Results A 57-year-old man with a large nonfunctional pituitary macroadenoma underwent an endoscopic transsphenoidal operation with gross total resection. An absorbable plate was placed extradurally to reconstruct the sellar floor. He experienced delayed repeated epistaxis, followed by a right middle cerebral artery distribution embolic stroke. Computed tomorgraphy (CT) angiogram 6 weeks postoperatively revealed a 6 × 4 mm pseudoaneurysm located on the medial wall of the right cavernous internal carotid artery. Stent coiling was used to successfully obliterate the pseudoaneurysm, and the patient fully recovered. Conclusion Delayed erosion of the carotid artery wall caused by a plate used to reconstruct the sellar floor may manifest with epistaxis or embolic stroke. The authors' preference is to avoid insertion of a rigid plate for sellar floor reconstruction in the absence of intraoperative cerebrospinal fluid (CSF) leaks, unless it is required to buttress a large skull base defect. Short-segment embolization with stent coiling is the preferred treatment option for carotid pseudoaneurysms following transsphenoidal operations.

No MeSH data available.


Related in: MedlinePlus

Digital subtraction angiogram showing right cavernous carotid pseudoaneurysm before and after stent-assisted coil embolization.
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FI120031-3: Digital subtraction angiogram showing right cavernous carotid pseudoaneurysm before and after stent-assisted coil embolization.

Mentions: A 57-year-old man with a nonfunctional pituitary macroadenoma causing vision loss underwent a gross total, endoscopic transsphenoidal resection (Fig. 1). The tumor was invading the right cavernous sinus wall. During the procedure to resect the tumor from this region, there was some venous bleeding that was easily controlled by temporarily packing the area using Gelfoam (Pfizer, New York, New York, USA) with thrombin. Following resection, a custom-fit bioabsorbable plate was placed extradurally to reconstruct the sellar floor. The patient was discharged home on postoperative day 2 in excellent condition. Four weeks later, he experienced epistaxis for which he was treated at an outside emergency department. The bleeding was controlled with nasal packs, and the patient was discharged home. Six weeks following the operation, he presented to clinic with dysarthria as well as left hand and facial weakness and was admitted for further work-up. Neuroimaging revealed subacute infarcts in right middle cerebral artery distribution. Computed tomography (CT) angiogram showed a 6 × 4 mm pseudoaneurysm located on the medial wall of the right cavernous internal carotid artery. A hypodensity likely representing the implanted absorbable plate was noted to be compressing the right carotid artery in this region (Fig. 2). Stent coiling with placement of eight detachable coils was used to successfully obliterate the pseudoaneurysm (Fig. 3). Follow-up digital subtraction angiogram and CT angiogram demonstrated durable obliteration of the pseudoaneurysm with preserved flow through the carotid artery. On follow-up, the patient's neurological deficits have resolved.


Delayed cavernous carotid artery pseudoaneurysm caused by absorbable plate following transsphenoidal surgery: case report and review of the literature.

Tuchman A, Khalessi AA, Attenello FJ, Amar AP, Zada G - J Neurol Surg Rep (2013)

Digital subtraction angiogram showing right cavernous carotid pseudoaneurysm before and after stent-assisted coil embolization.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3713556&req=5

FI120031-3: Digital subtraction angiogram showing right cavernous carotid pseudoaneurysm before and after stent-assisted coil embolization.
Mentions: A 57-year-old man with a nonfunctional pituitary macroadenoma causing vision loss underwent a gross total, endoscopic transsphenoidal resection (Fig. 1). The tumor was invading the right cavernous sinus wall. During the procedure to resect the tumor from this region, there was some venous bleeding that was easily controlled by temporarily packing the area using Gelfoam (Pfizer, New York, New York, USA) with thrombin. Following resection, a custom-fit bioabsorbable plate was placed extradurally to reconstruct the sellar floor. The patient was discharged home on postoperative day 2 in excellent condition. Four weeks later, he experienced epistaxis for which he was treated at an outside emergency department. The bleeding was controlled with nasal packs, and the patient was discharged home. Six weeks following the operation, he presented to clinic with dysarthria as well as left hand and facial weakness and was admitted for further work-up. Neuroimaging revealed subacute infarcts in right middle cerebral artery distribution. Computed tomography (CT) angiogram showed a 6 × 4 mm pseudoaneurysm located on the medial wall of the right cavernous internal carotid artery. A hypodensity likely representing the implanted absorbable plate was noted to be compressing the right carotid artery in this region (Fig. 2). Stent coiling with placement of eight detachable coils was used to successfully obliterate the pseudoaneurysm (Fig. 3). Follow-up digital subtraction angiogram and CT angiogram demonstrated durable obliteration of the pseudoaneurysm with preserved flow through the carotid artery. On follow-up, the patient's neurological deficits have resolved.

Bottom Line: To date, iatrogenic carotid pseudoaneurysm associated with the use of an absorbable plate has been reported once.The authors' preference is to avoid insertion of a rigid plate for sellar floor reconstruction in the absence of intraoperative cerebrospinal fluid (CSF) leaks, unless it is required to buttress a large skull base defect.Short-segment embolization with stent coiling is the preferred treatment option for carotid pseudoaneurysms following transsphenoidal operations.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

ABSTRACT
Background Bioabsorbable plates are frequently utilized in the repair of skull base defects following transsphenoidal operations. Traumatic intracranial pseudoaneurysms are a rare complication of transsphenoidal surgery. To date, iatrogenic carotid pseudoaneurysm associated with the use of an absorbable plate has been reported once. Results A 57-year-old man with a large nonfunctional pituitary macroadenoma underwent an endoscopic transsphenoidal operation with gross total resection. An absorbable plate was placed extradurally to reconstruct the sellar floor. He experienced delayed repeated epistaxis, followed by a right middle cerebral artery distribution embolic stroke. Computed tomorgraphy (CT) angiogram 6 weeks postoperatively revealed a 6 × 4 mm pseudoaneurysm located on the medial wall of the right cavernous internal carotid artery. Stent coiling was used to successfully obliterate the pseudoaneurysm, and the patient fully recovered. Conclusion Delayed erosion of the carotid artery wall caused by a plate used to reconstruct the sellar floor may manifest with epistaxis or embolic stroke. The authors' preference is to avoid insertion of a rigid plate for sellar floor reconstruction in the absence of intraoperative cerebrospinal fluid (CSF) leaks, unless it is required to buttress a large skull base defect. Short-segment embolization with stent coiling is the preferred treatment option for carotid pseudoaneurysms following transsphenoidal operations.

No MeSH data available.


Related in: MedlinePlus