1
|
Ma X, Zhang Y, Yang ZJ, Bo W, Wang XC, Zhang C, Liu PN, Bi ZY. Internal carotid artery injury during endoscopic transsphenoidal pituitary surgery: risk factors, management. Neurochirurgie 2024; 70:101515. [PMID: 38052154 DOI: 10.1016/j.neuchi.2023.101515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/25/2023] [Accepted: 11/14/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Transsphenoidal surgeons should try to avoid internal carotid artery (ICA) injury but also be prepared to manage it. We analyzed our experience with ICA injury during endoscopic transsphenoidal pituitary surgery and present associated risk factors and a management protocol. METHODS We retrospectively reviewed and analyzed the medical records of 1596 patients who underwent endoscopic transsphenoidal surgery for pituitary tumor resection in our institution from January 2009 to October 2022. RESULTS Six patients experienced an ICA injury. All received timely and effective hemostasis with immediate direct tamponade followed by endovascular treatment. No serious postoperative complications occurred. CONCLUSIONS We proposed a treatment plan for ICA injuries encountered during endoscopic transsphenoidal surgery and described our hemostasis process, methods of endovascular treatment, and means of postoperative follow-up in detail.
Collapse
Affiliation(s)
- Xin Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Yu Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Zhi-Jun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University, Beijing, China
| | - Wang Bo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University, Beijing, China
| | - Xin-Chao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University, Beijing, China
| | - Chao Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pi-Nan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University, Beijing, China.
| | - Zhi-Yong Bi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
2
|
Dao Trong P, Jesser J, Schneider T, Unterberg A, Beynon C. Interracial anatomical differences in the transsphenoidal approach to the sellar region. Br J Neurosurg 2023; 37:1006-1009. [PMID: 33956553 DOI: 10.1080/02688697.2020.1834506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Injury to vascular structures such as the internal carotid artery (ICA) is a rare but catastrophic complication of minimally invasive transsphenoidal surgery. Thorough preoperative planning, and knowledge of anatomical landmarks, such as the intercarotid distance (ICD) reduce this risk. Numerous anatomical studies have been conducted regarding the transsphenoidal approach, but none have taken racial disparities into account. METHODS Since differences of the cranium, especially of the skull base exist, we sought to analyze anatomical differences of the sellar region in thin sliced T2-weighted MRI scans of 187 (87 male and 100 female) Asian, African American and Caucasian patients provided by the 'Human Connectome Project' (HCP). RESULTS We found significant differences in the ICD between males and females across all races. Furthermore, we found that the ICD was up to 2.4 mm smaller in the Caucasian cohort compared to the African American/Asian cohort. CONCLUSION These findings indicate that racial disparities regarding the sellar anatomy should be considered in patients undergoing pituitary surgery.
Collapse
Affiliation(s)
- Philip Dao Trong
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Till Schneider
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Christopher Beynon
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
3
|
Ghorbani M, Hejazian E, Nikmanzar S, Chavoshi-Nejad M. Traumatic iatrogenic dissecting anterior cerebral artery aneurysms: conservative management as a therapeutic option. Br J Neurosurg 2023; 37:896-898. [PMID: 31983243 DOI: 10.1080/02688697.2020.1713988] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/20/2019] [Accepted: 12/30/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Traumatic iatrogenic intracranial aneurysms (TICAs) are rare, but are important due to their risk of intracranial hemorrhage and complexity of management. METHODS Two adult patients, one with history of chronic sinusitis and nasal cavity polyposis undergoing functional endoscopic sinus surgery (FESS), and second during rhinoplasty, suffered subarachnoid hemorrhage (SAH) due to anterior cerebral artery (ACA) injury during the procedures. RESULTS Two women patients aged 17 and 38 years with SAH after nasal surgery were referred to our institute. Three small dissecting aneurysms were seen involving A2 segment of ACA of two patients. Both were managed conservatively. Follow-up angiography (after 2 months) demonstrated complete occlusion of the aneurysms. There was no rebleeding and the patients had a good outcome at the last follow-up. CONCLUSIONS Conservative management of traumatic iatrogenic dissecting cerebral aneurysms is a reasonable therapeutic option that can lead to favorable angiographic and clinical outcomes.
Collapse
Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ebrahim Hejazian
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shahin Nikmanzar
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Chavoshi-Nejad
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
4
|
Sharma AK, Jagetia A, Singhal GD, Bodeliwala S, Srivastava AK, Singh D. Treatment Dilemma of Latrogenic Pseudoaneurysm of the Intracavernous Internal Carotid Artery in Young Girl Following Transnasal Transsphenoidal Surgery: A Case Report. Asian J Neurosurg 2022; 17:112-115. [PMID: 35873853 PMCID: PMC9298596 DOI: 10.1055/s-0042-1749178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Epistaxis following transnasal transsphenoidal (TNTS) removal of pituitary adenoma can be massive and life-threatening. The intracranial source of bleeding is usually the intracavernous segment of the internal carotid artery (ICA) or adjacent branches. Injury to the cavernous ICA can lead to pseudoaneurysm (PA) or fistula formation. Management of PA is different from saccular aneurysms. A timely diagnosis and adequate management can restore vessel integrity and prevent associated morbidity. A young patient of growth hormone-secreting pituitary adenoma, who underwent microscopic TNTS excision of the tumour, presented with massive epistaxis. Pseudoaneurysm of the cavernous ICA was initially not seen on computed tomography angiography and was later diagnosed on digital subtraction angiography. The attempted management of PA with coils without stent could not stop aneurysm recurrence. The management of such complicated PAs is discussed, and a literature review is done regarding epistaxis in growth hormone secreting adenoma.
Collapse
Affiliation(s)
- Amit K. Sharma
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Anita Jagetia
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ghanshyam D Singhal
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Shaam Bodeliwala
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Arvind K. Srivastava
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Daljit Singh
- Department of Neurosurgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| |
Collapse
|
5
|
Tan S, Zhou X, Lu Y, Lai L, Huang X, Li B, Wang Y. Low-profile visualized intraluminal support stent for the endovascular treatment of traumatic intracranial internal carotid artery pseudoaneurysms. Neurosurg Rev 2022; 45:2231-2237. [PMID: 35067805 DOI: 10.1007/s10143-021-01714-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/05/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
Optimal treatment strategies for traumatic intracranial internal carotid artery (ICA) pseudoaneurysms are controversial. The low-profile visualized intraluminal support (LVIS) device is a braided stent with a metal coverage rate between traditional laser cut stents and flow diversion devices. We report here our therapy strategy using the LVIS stent-assisted coiling for treatment of traumatic intracranial ICA pseudoaneurysms. Patients with traumatic intracranial ICA pseudoaneurysms treated by the LVIS stent-assisted coiling in our center between January 2015 and June 2021 were reviewed. The complications, radiographic, and clinical outcomes of these patients were analyzed. A total of 12 patients with 12 pseudoaneurysms were included. The mean maximum aneurysm diameter was 6.2 ± 3.1 mm. Nine patients had a subarachnoid hemorrhage; five patients with Hunt-Hess grade III and four patients with grade IV. All procedures were successfully performed without intraoperative complications. Immediate postoperative angiogram showed that six (50%) aneurysms were Raymond grade 1, four (33.3%) were grade 2, and two (16.7%) were grade 3. Postoperative multiple cerebral infarction occurred in two patients because of vasospasm. Of the ten patients with angiographic follow-up (mean, 29.9 months), two received additional coiling because of recanalization of the pseudoaneurysm, and all aneurysms were completely obliterated at the last examination of the patients. During the clinical follow-up period (mean, 26.8 months), the overall mortality and morbidity were 25% (3/12) and 8.3% (1/12), respectively. LVIS stent-assisted coiling was a feasible approach for the treatment of traumatic ICA pseudoaneurysms.
Collapse
Affiliation(s)
- Song Tan
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi, China
| | - Xiaobing Zhou
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi, China
| | - Yuzhao Lu
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi, China
| | - Lingfeng Lai
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi, China
| | - Xiaofei Huang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi, China
| | - Bin Li
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi, China
| | - Yang Wang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang University, Nanchang, Jiangxi, China. .,Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 10043, China.
| |
Collapse
|
6
|
Kahilogullari G, Bahadır B, Bozkurt M, Akcalar S, Balci S, Arat A. Carotid Artery-Cavernous Segment Injury during an Endoscopic Endonasal Surgery: A Case Report and Literature Review of the Overlooked Option for Surgical Trapping in the Hyperacute Phase. J Neurol Surg Rep 2021; 82:e53-e62. [PMID: 34917447 PMCID: PMC8670996 DOI: 10.1055/s-0041-1740511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/20/2021] [Indexed: 10/26/2022] Open
Abstract
Internal carotid artery (ICA) injury is a catastrophic complication of endoscopic endonasal surgery (EES). However, its standard management, emergent endovascular treatment, may not always be available, and the transnasal approach may be insufficient to achieve hemostasis. A 44-year-old woman with pituitary adenoma underwent EES complicated with the ICA cavernous segment injury (CSI). In urgent intraoperative angiogram, a good collateral flow from the contralateral carotid circulation was observed. Due to the unavailability of intraoperative embolization, emergent surgical trapping was performed by combined transcranial and cervical approach. The patient recovered but later developed a giant cavernous pseudoaneurysm. During the pseudoaneurysm embolization, ICA was directly accessed via a 1.7-F puncture hole using a bare microcatheter technique. Then, both the aneurysm and parent artery were obliterated with coils. At the 4-year follow-up, the patient was asymptomatic without a residual tumor. To our knowledge, this is the first case of ICA-CSI during EES successfully treated with ICA trapping as a lifesaving urgent surgery that achieved a complete recovery after a pseudoaneurysm embolization. Although several studies reported that EES-related ICA-CSIs with percutaneous carotid artery access, neither our surgical salvage technique nor our carotid access and tract embolization techniques were previously described.
Collapse
Affiliation(s)
| | - Burak Bahadır
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Melih Bozkurt
- Department of Neurosurgery, Ankara University, Ankara, Turkey
| | - Seray Akcalar
- Department of Radiology, Ankara University, Ankara, Turkey
| | - Sinan Balci
- Department of Radiology, Hacettepe University, Ankara, Turkey
| | - Anil Arat
- Department of Radiology, Hacettepe University, Ankara, Turkey
| |
Collapse
|
7
|
del Pont FM, Villalonga JF, Sáenz A, Caffaratti G, Alcorta SC, Cervio A. Pseudoaneurysm following Surgical Resection of Craniopharyngioma: What Is the Best Management? INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1729462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractCraniopharyngiomas are benign tumors of the sellar and parasellar region for which surgical resection remains the treatment of choice. There are many publications on the most frequent postoperative complications, but few reports on subclinical lesions affecting the arteries of the circle of Willis, despite their high morbidity and mortality rate. Trauma-induced aneurysms are infrequent, representing less than 1% of intracranial aneurysms. Iatrogenic intracranial pseudoaneurysms are a subtype of surgically induced aneurysms developed as a result of direct injury to the arterial wall or after dissection of tumors adherent to the vessel adventitia. The natural history of these lesions is not well known because their incidence is extremely low. We report two cases of postoperative aneurysms of the internal carotid artery after craniopharyngioma resection and a brief review on the management of such lesions.
Collapse
Affiliation(s)
| | | | - Amparo Sáenz
- Departamento de Neurocirugia, Fleni, Buenos Aires, Argentina
- Departamento de Neurocirugia, Hospital de Pediatria Juan P. Garrahan, Buenos Aires, Argentina
| | | | | | - Andrés Cervio
- Departamento de Neurocirugia, Fleni, Buenos Aires, Argentina
| |
Collapse
|
8
|
Zheng Y, Lu Z, Shen J, Xu F. Intracranial Pseudoaneurysms: Evaluation and Management. Front Neurol 2020; 11:582. [PMID: 32733358 PMCID: PMC7358534 DOI: 10.3389/fneur.2020.00582] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/20/2020] [Indexed: 12/04/2022] Open
Abstract
Intracranial pseudoaneurysms account for about 1% of intracranial aneurysms with a high mortality. The natural history of intracranial pseudoaneurysm is not well-understood, and its management remains controversial. This review provides an overview of the etiology, pathophysiology, clinical presentation, imaging, and management of intracranial pseudoaneurysms. Especially, this article emphasizes the factors that should be considered for the most appropriate management strategy based on the risks and benefits of each treatment option.
Collapse
Affiliation(s)
- Yongtao Zheng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China
| | - Zheng Lu
- Department of Neurosurgery, Hai'an People's Hospital, Nantong, China
| | - Jianguo Shen
- Department of Neurosurgery, Second Affiliated Hospital of Jiaxiang University, Jiaxing, China
| | - Feng Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical School, Fudan University, Shanghai, China.,Department of Neurosurgery, Kashgar Prefecture Second People's Hospital, Kashgar, China
| |
Collapse
|
9
|
Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Zhang Y, Tian Z, Li C, Liu J, Zhang Y, Yang X, Zhang Y. A modified endovascular treatment protocol for iatrogenic internal carotid artery injuries following endoscopic endonasal surgery. J Neurosurg 2020; 132:343-350. [PMID: 30684942 DOI: 10.3171/2018.8.jns181048] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/28/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Internal carotid artery (ICA) injuries during endoscopic endonasal surgery (EES) are catastrophic complications. Alongside the advancements in medical instrumentation and material, there is a need to modify previous treatment modalities and principles. METHODS A retrospective review of 3658 patients who underwent EES performed at the authors' institution between January 2012 and December 2017 was conducted. Ultimately, 20 patients (0.55%) with ICA injury following EES were enrolled for analysis. Data collection included demographic data, preoperative diagnosis, injury setting, repair method, and immediate and follow-up angiographic and clinical outcomes. RESULTS Among the 20 patients, 11 received immediate endovascular therapy and 9 were treated only with packing. Of the 11 patients who received endovascular treatment, 6 were treated by covered stent and 5 by parent artery occlusion (PAO). The preservation rate of injured ICA increased from 20.0% (1 of 5) to 83.3% (5 of 6) after the Willis covered stent graft became available in January 2016. Of the 20 patients in the study, 19 recovered well and 1 patient-who had a pseudoaneurysm and was treated by PAO with a detachable balloon-suffered epistaxis after the hemostat in her nasal cavity was removed in ward, and she died later that day. The authors speculated that the detachable balloon had shifted to the distal part of ICA, although the patient could not undergo a repeat angiogram because she quickly suffered shock and could not be transferred to the catheter room. After the introduction of a hybrid operating room (OR), one patient whose first angiogram showed no ICA injury was found to have a pseudoaneurysm. He received endovascular treatment when he was brought for a repeat angiogram 5 days later in the hybrid OR after removing the hemostat in his nasal cavity. Of the 4 surviving patients treated with PAO, no external carotid artery-ICA bypass was required. The authors propose a modified endovascular treatment protocol for ICA injuries suffered during EES that exploits the advantage of the covered stent graft and the hybrid OR. CONCLUSIONS The endovascular treatment protocol used in this study for ICA injuries during EES was helpful in the management of this rare complication. Willis stent placement improved the preservation rate of injured ICA during EES. It would be highly advantageous to manage this complication in a hybrid OR or by a mobile C-arm to get a clear intraoperative angiogram.
Collapse
Affiliation(s)
- Yisen Zhang
- Departments of1Interventional Neuroradiology and
| | | | - Chuzhong Li
- 2Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University.,3Key Laboratory of Central Nervous System Injury Research, Beijing.,4Beijing Institute for Brain Disorders Brain Tumor Center; and.,5China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jian Liu
- Departments of1Interventional Neuroradiology and
| | - Ying Zhang
- Departments of1Interventional Neuroradiology and
| | - Xinjian Yang
- Departments of1Interventional Neuroradiology and
| | - Yazhuo Zhang
- 2Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University.,3Key Laboratory of Central Nervous System Injury Research, Beijing.,4Beijing Institute for Brain Disorders Brain Tumor Center; and.,5China National Clinical Research Center for Neurological Diseases, Beijing, China
| |
Collapse
|
11
|
Podlesek D, Zolal A, Kirsch M, Schackert G, Pinzer T, Hummel T. Olfactory bulb volume changes associated with trans-sphenoidal pituitary surgery. PLoS One 2019; 14:e0224594. [PMID: 31851684 PMCID: PMC6919594 DOI: 10.1371/journal.pone.0224594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/17/2019] [Indexed: 11/20/2022] Open
Abstract
Objective The trans-sphenoidal approach is most frequently used for pituitary adenoma (PA) enucleation. However, effects of this surgery on neighboring structures have received little attention so far. In particular, no investigations on olfactory bulb (OB) anatomy after trans-sphenoidal surgery have been reported. Because impairment of olfaction has been shown in small groups following trans-sphenoidal surgery we hypothesized that the transnasal approach is likely to alter OB volume which is associated with changes of olfactory function. Methods The study comprised 33 patients with pituitary adenoma (14 women and 19 men, mean age 50 years). Comprehensive assessment of olfactory function was conducted with the "Sniffin' Sticks" test kit. Based on magnetic resonance imaging scans OBs were measured before and approximately one year after trans-sphenoidal PA enucleation. Results Owing to postoperative non-compliance and MRI artifacts partly due to drill friction complete evaluation of “Sniffin' Sticks” in term of obtaining the TDI score was possible pre- and postoperatively in 21 patients whereas OB volumes were available in 32 patients. Approximately one year after surgery olfactory function was not significantly different from baseline. However, left- and right-sided OB volume in patients treated via trans-sphenoidal surgery decreased (p = 0.001). The side of the surgical approach did not affect OB volume in a side-specific manner. Changes in odor threshold were significantly correlated to changes in right-sided OB volume (r = 0.45, p = 0.024). Conclusion Overall olfactory performance one year after surgery was not significantly different from baseline. However, changes in OB volume are associated with changes in olfactory performance and OB volumes decreased in patients.
Collapse
Affiliation(s)
- Dino Podlesek
- Department of Neurosurgery, Dresden University of Technology, Carl Gustav Carus Faculty of Medicine, Dresden, Germany
- * E-mail:
| | - Amir Zolal
- Department of Spine Surgery and Neurotraumatology, SRH-Wald Clinic Gera, Gera, Germany
| | - Matthias Kirsch
- Department of Neurosurgery, Asklepios Clinic Schildautal Seesen, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, Dresden University of Technology, Carl Gustav Carus Faculty of Medicine, Dresden, Germany
| | - Thomas Pinzer
- Department of Neurosurgery, Dresden University of Technology, Carl Gustav Carus Faculty of Medicine, Dresden, Germany
| | - Thomas Hummel
- Interdisciplinary Smell & Taste Clinic, Department of Otorhinolaryngology, Dresden University of Technology, Carl Gustav Carus Faculty of Medicine, Dresden, Germany
| |
Collapse
|
12
|
Faden DL, Hughes MA, Lavigne P, Jankowitz BT, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Diagnosis and endoscopic endonasal management of nontraumatic pseudoaneurysms of the cranial base. Int Forum Allergy Rhinol 2018; 8:641-647. [DOI: 10.1002/alr.22080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Daniel L. Faden
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Marion A. Hughes
- Department of Radiology; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Philippe Lavigne
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Brian T. Jankowitz
- Department of Neurological Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Eric W. Wang
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh PA
| | | | - Paul A. Gardner
- Department of Neurological Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA
| | - Carl H. Snyderman
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh PA
| |
Collapse
|
13
|
Alzhrani G, Sivakumar W, Park MS, Taussky P, Couldwell WT. Delayed Complications After Transsphenoidal Surgery for Pituitary Adenomas. World Neurosurg 2018; 109:233-241. [DOI: 10.1016/j.wneu.2017.09.192] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
|
14
|
Transcranial Evacuation of Atypical Progressive Supradiaphragmatic Hematoma After Transsphenoidal Complete Resection of Pituitary Adenoma. World Neurosurg 2017; 102:487-493. [PMID: 28347892 DOI: 10.1016/j.wneu.2017.03.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/16/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Supradiaphragmatic hematoma is a type of hematoma that occurs after transsphenoidal (TS) resection of pituitary adenoma and requires special management. METHODS Two patients had symptomatic supradiaphragmatic hematomas after total TS resection of pituitary adenomas in the absence of vascular anomalies. Both patients also had hydrocephalus at the time of diagnosis of the hematoma. The initial endoscopic endonasal inspection showed no subdiaphragmatic bleeding. The hematoma was evacuated via a frontolateral approach after insertion of an external ventricular drain (EVD). RESULTS The supradiaphragmatic hematoma could be clinically and radiologically distinguished. It presented early with visual deterioration without headache. The patients developed hydrocephalus, which was associated with deterioration of level of consciousness. Radiologically, the hematoma filled the suprasellar space and was associated with the extension of bleeding in the basal cisterns. Recovery was good in both patients. There were no permanent neurologic deficits. The EVD was removed in both patients. One patient required a ventriculoperitoneal shunt because of delayed hydrocephalus. CONCLUSIONS Supradiaphragmatic hematoma can be clinically and radiologically distinguished from other types of hematoma occurring after TS resection of pituitary adenoma. Transcranial surgery should be performed to manage supradiaphragmatic hematoma, when symptomatic. Insertion of an EVD at the time of evacuation is mandatory to relax the brain and to alleviate the hydrocephalus.
Collapse
|
15
|
Ciporen JN, Lucke-Wold B, Mendez G, Cameron WE, McCartney S. Endoscopic Management of Cavernous Carotid Surgical Complications: Evaluation of a Simulated Perfusion Model. World Neurosurg 2017; 98:388-396. [PMID: 27840204 PMCID: PMC5490663 DOI: 10.1016/j.wneu.2016.11.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Endoscopic surgical treatment of pituitary tumors, lateral invading tumors, or aneurysms requires surgeons to operate adjacent to the cavernous sinus. During these endoscopic endonasal procedures, the carotid artery is vulnerable to surgical injury at its genu. The objective of this simulation model was to evaluate trainees regarding management of a potentially life-threatening vascular injury. METHODS Cadaveric heads were prepared in accordance with the Oregon Health & Science University body donation program. An endoscopic endonasal approach was used, and a perfusion pump with a catheter was placed in the ipsilateral common carotid artery at its origin in the neck. Learners used a muscle graft to establish vascular control and were evaluated over 3 training sessions. Simulation assessment, blood loss during sessions, and performance metric data were collected for learners. RESULTS Vascular control was obtained at a mean arterial pressure of 65 mm Hg using a muscle graft correctly positioned at the arteriotomy site. Learners improved over the course of training, with senior residents (n = 4) performing better across all simulation categories (situation awareness, decision making, communications and teamwork, and leadership); the largest mean difference was in communication and teamwork. Additionally, learner performance concerning blood loss improved between sessions (t = 3.667, P < 0.01). CONCLUSIONS In this pilot endoscopic endonasal simulation study, we successfully demonstrate a vascular complication perfusion model. Learners were able to gain direct applicable expertise in endoscopic endonasal techniques, instrumentation use, and teamwork required to optimize the technique. Learners gained skills of vascular complication management that transcend this model.
Collapse
Affiliation(s)
- Jeremy N Ciporen
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
| | - Brandon Lucke-Wold
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Gustavo Mendez
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - William E Cameron
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, Oregon, USA
| | - Shirley McCartney
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
16
|
Kalinin PL, Sharipov OI, Pronin IN, Kutin MA, Fomichev DV, Kadashev BA, Shkarubo AN, Alekseev SN, Astaf'eva LI, Tropinskaya OF, Dobrovol'skiy GF, Shul'ts EI, Andreev DN, Voronina IA, Kurnosov AB. [Endoscopic transsphenoidal resection of pituitary adenomas invading the cavernous sinus]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2017; 80:63-74. [PMID: 27500775 DOI: 10.17116/neiro201680463-74] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Pituitary adenomas are benign growths that invade the cavernous sinus (CS) in 10-15% of cases. There are different types of microsurgical and endoscopic approaches enabling resection of tumors from the CS cavity that is a relatively small and hard to reach anatomical structure comprising eloquent neurovascular structures. MATERIAL AND METHODS A study group included 97 patients with pituitary adenomas (PAs) invading the CS. PAs were resected using an endoscopic technique: adenomas were resected from the CS cavity through a standard endoscopic endonasal transsphenoidal approach in 62 cases; a lateral extended transsphenoidal endoscopic approach was used in 35 cases. A control group included patients with PAs spreading into the laterosellar region who were operated on using microsurgical extra-intradural (n=14) and transsphenoidal (n=149) approaches. In the study group, the degree of PA invasion into the CS cavity was determined using the Knosp scale. RESULTS In the study group, total tumor resection was achieved in 49 (50.5%) cases, subtotal resection in 39 (40.2%) cases, and partial resection in 9 (9.3%) patients. In the case of visual disorders (n=70), vision improvement was achieved in 41.4% of cases. Vision deterioration was detected in 11.4% of cases; no vision changes were in 47.1% of cases. Patients (27.8%) who had not had visual impairments before surgery had no negative changes in vision in the postoperative period. The development/augmentation of oculomotor disorders in the study group occurred in 14 (14.4%) cases. In the study group, hormonal remission of the disease in patients with hormone-active PAs was in 26.7% of cases (n=12). There were no cases of nasal liquorrhea, meningitis, and death in the study group. CONCLUSION Endoscopic endonasal transsphenoidal resection of PAs invading the CS is a more efficient and safer surgical technique compared to microsurgical techniques (transsphenoidal and extra-intradural approach). The lateral extended transsphenoidal endoscopic approach enables resection of PAs with massive invasion into the CS (Grade III and Grade IV, Knosp scale) and has less postoperative complications compared to the extra-intradural approach (p<0.05).
Collapse
Affiliation(s)
- P L Kalinin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - O I Sharipov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - M A Kutin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D V Fomichev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - B A Kadashev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A N Shkarubo
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - S N Alekseev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | | | - E I Shul'ts
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D N Andreev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I A Voronina
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A B Kurnosov
- Burdenko Neurosurgical Institute, Moscow, Russia
| |
Collapse
|
17
|
Ciporen J, Lucke-Wold B, Dogan A, Cetas JS, Cameron WE. Dual Endoscopic Endonasal Transsphenoidal and Precaruncular Transorbital Approaches for Clipping of the Cavernous Carotid Artery: A Cadaveric Simulation. J Neurol Surg B Skull Base 2016; 77:485-490. [PMID: 27857875 PMCID: PMC5112163 DOI: 10.1055/s-0036-1584094] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/22/2016] [Indexed: 02/08/2023] Open
Abstract
Background Endoscopic skull base approaches are being used to address complicated neurovascular pathology. These approaches are safest when proximal vascular control of the cavernous carotid artery (CavCA) can be obtained. Methods We present a cadaver-based anatomic simulation study showing the feasibility of clip placement for the CavCA as it courses through the cavernous sinus. The arterial vessels were injected with red microfil (Flow Tech, Carver, Massachusetts) to enhance visibility. The endoscope was directed through a precaruncular transorbital approach and instrumentation was managed through an endonasal transsphenoidal approach. Results The dual approach minimized the "coning down" and instrument "sword fighting" that occurs as the rod lens endoscope and instruments are used laterally and posterior toward the clivus and brainstem. The precaruncular transorbital approach improved visualization of the clip application and improved the functional working area. The transorbital port allowed better appreciation of the distal clip tines, and the laterally positioned cranial nerves. Conclusions The advantages may be most realized in the setting of endoscopic endonasal resection of highly vascular lesions and/or bleeding from a ruptured aneurysm being clipped. Simulated training provides an excellent opportunity to enhance skill sets and increase familiarity with anatomical visualization before entering the operative arena.
Collapse
Affiliation(s)
- Jeremy Ciporen
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, United States
- Address for correspondence Jeremy Ciporen, MD Department of Neurological Surgery, Oregon Health & Science UniversityCenter for Health and Healing, CH8N, 3303 SW Bond Avenue, Portland, OR 97239United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, United States
| | - Aclan Dogan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, United States
| | - Justin S. Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, United States
| | - William E. Cameron
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, Oregon, United States
| |
Collapse
|
18
|
Abdulrauf SI, Ashour AM, Marvin E, Coppens J, Kang B, Hsieh TYY, Nery B, Penanes JR, Alsahlawi AK, Moore S, Abou Al-Shaar H, Kemp J, Chawla K, Sujijantarat N, Najeeb A, Parkar N, Shetty V, Vafaie T, Antisdel J, Mikulec TA, Edgell R, Lebovitz J, Pierson M, Pires de Aguiar PH, Buchanan P, Di Cosola A, Stevens G. Proposed clinical internal carotid artery classification system. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2016; 7:161-70. [PMID: 27630478 PMCID: PMC4994148 DOI: 10.4103/0974-8237.188412] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. MATERIALS AND METHODS We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. RESULTS The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%]; P < 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%]; P < 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%]; P < 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%; P < 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%]; P < 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. CONCLUSIONS The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.
Collapse
Affiliation(s)
- Saleem I Abdulrauf
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Ahmed M Ashour
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Eric Marvin
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jeroen Coppens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Brian Kang
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tze Yu Yeh Hsieh
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Breno Nery
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Juan R Penanes
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Aysha K Alsahlawi
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Shawn Moore
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Hussam Abou Al-Shaar
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Joanna Kemp
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Kanika Chawla
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nanthiya Sujijantarat
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Alaa Najeeb
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nadeem Parkar
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Vilaas Shetty
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tina Vafaie
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jastin Antisdel
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tony A Mikulec
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Randall Edgell
- Department of Neurology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jonathan Lebovitz
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Matt Pierson
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | | | - Paula Buchanan
- Center for Outcomes Research, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Angela Di Cosola
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - George Stevens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| |
Collapse
|
19
|
Katzir M, Gil Z, Cohen JE, Sviri GE. Cavernous Carotid Artery Pseudoaneurysm Following a Radical Cavernous Sinus Resection. J Neurol Surg Rep 2016; 77:e102-5. [PMID: 27330923 PMCID: PMC4914395 DOI: 10.1055/s-0036-1584282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Iatrogenic cavernous carotid pseudoaneurysms are a special group among other intracranial aneurysms. They can occur during the dissection phase of the surgery if the tumor encases a vessel. Complications of their rupture as hemorrhage or stroke are life threatening. Early recognition and treatment is mandatory to avoid catastrophic sequelae. We present the successful diagnosis and endovascular treatment of a postoperative cavernous carotid pseudoaneurysm following radical cavernous sinus resection.
Collapse
Affiliation(s)
- Miki Katzir
- Department of Neurosurgery, The Technion, Israel Institute of Technology, Haifa, Israel
| | - Ziv Gil
- Department of Otolaryngology Head and Neck Surgery, The Technion, Israel Institute of Technology, Haifa, Israel
| | - José Enrique Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Gill Efraim Sviri
- Department of Neurosurgery, The Technion, Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
20
|
Hsu CP, Chang CK, Chiang MF, Tsai CC, Chen SJ. Endoscopic endonasal trans-sphenoidal approach for pituitary fossa tumor: Outcome analysis of 39 consecutive procedures. JOURNAL OF CANCER RESEARCH AND PRACTICE 2016. [DOI: 10.1016/j.jcrpr.2015.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
21
|
Sylvester PT, Moran CJ, Derdeyn CP, Cross DT, Dacey RG, Zipfel GJ, Kim AH, Uppaluri R, Haughey BH, Tempelhoff R, Rich KM, Schneider J, Chole RA, Chicoine MR. Endovascular management of internal carotid artery injuries secondary to endonasal surgery: case series and review of the literature. J Neurosurg 2016; 125:1256-1276. [PMID: 26771847 DOI: 10.3171/2015.6.jns142483] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Internal carotid artery (ICA) injury is a rare but severe complication of endonasal surgery. The authors describe their endovascular experience managing ICA injuries after transsphenoidal surgery; they review and summarize the current literature regarding endovascular techniques; and they propose a treatment algorithm based on the available evidence. METHODS A retrospective review of 576 transsphenoidal pituitary adenoma resections was performed. Cases of ICA injury occurring at our institution and transfers from other hospitals were evaluated. Endovascular treatments for ICA injury reported in the literature were also reviewed and summarized. RESULTS Seven cases were identified from the institutional cohort (mean age 46.3 years, mean follow-up 43.4 months [1-107 months]) that received endovascular treatment for ICA injury. Five injuries occurred at our institution (5 [0.9%] of 576), and 2 injuries occurred at outside hospitals. Three patients underwent ICA sacrifice by coil placement, 2 underwent lesion embolization (coil or stent-assisted coil placement), and 2 underwent endoluminal reconstruction (both with flow diversion devices). Review of the literature identified 98 cases of ICA injury treated with endovascular methods. Of the 105 total cases, 46 patients underwent ICA sacrifice, 28 underwent lesion embolization, and 31 underwent endoluminal reconstruction. Sacrifice of the ICA proved a durable solution in all cases; however, the rate of persistent neurological complications was relatively high (10 [21.7%] of 46). Lesion embolization was primarily performed by coil embolization without stenting (16 cases) and stent-assisted coiling (9 cases). Both techniques had a relatively high rate of at least some technical complication (6 [37.5%] of 16 and 5 [55.6%] of 9, respectively) and major technical complications (i.e., injury, new neurological deficit, or ICA sacrifice) (5 [31.3%] of 16 and 2 [22.2%] of 9, respectively). Endoluminal reconstruction was performed by covered stent (24 cases) and flow diverter (5 cases) placement. Covered stents showed a reasonably high rate of technical complications (10 [41.7%] of 24); however, 8 of these problems were resolved, leaving a small percentage with major technical complications (2 [8.3%] of 24). Flow diverter placement was also well tolerated, with only 1 minor technical complication. CONCLUSIONS Endovascular treatments including vessel sacrifice, coil embolization (with or without stent assistance), and endoluminal reconstruction offer a tailored approach to ICA injury management after endonasal surgery. Vessel sacrifice remains the definitive treatment for acute, uncontrolled bleeding; however, vessel preservation techniques should be considered carefully in select patients. Multiple factors including vascular anatomy, injury characteristics, and risk of dual antiplatelet therapy should guide best treatment, but more study is needed (particularly with flow diverters) to refine this decision-making process. Ideally, all endovascular treatment options should be available at institutions performing endonasal surgery.
Collapse
Affiliation(s)
| | - Christopher J Moran
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - Colin P Derdeyn
- Departments of 1 Neurosurgery.,Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | - DeWitte T Cross
- Division of Neuroradiology, Mallinckrodt Institute, Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Chin OY, Ghosh R, Fang CH, Baredes S, Liu JK, Eloy JA. Internal carotid artery injury in endoscopic endonasal surgery: A systematic review. Laryngoscope 2015; 126:582-90. [PMID: 26525334 DOI: 10.1002/lary.25748] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS Internal carotid artery (ICA) injury during endoscopic endonasal surgery (EES) is a known and feared complication of paranasal sinus and skull base procedures. These ICA injuries can result in stroke, cranial nerve palsies, and death. This review examines the setting of injury along with the treatment approaches, and patient outcomes. STUDY DESIGN Systematic review using PubMed/MEDLINE and EMBASE. METHODS The databases were searched for articles reporting cases of ICA injury during EES. Variables analyzed included patient demographics, operative approach, preoperative diagnosis, setting of injury, repair method, imaging studies, patient outcomes, and follow-up. RESULTS Twenty-five articles with 50 cases were included in this review. The EES approach was used for skull base procedures in 34 cases and for inflammatory disease in 16 cases. The most commonly injured ICA segment was the cavernous (34 cases), followed by the ophthalmic (three cases). Injuries occurred more commonly on the left (1.3:1). Injury occurred in the setting of various steps during EES with instruments. Stereotactic image guidance was reported in two cases. Initial hemostasis was achieved with packing in 35 cases, endoscopic clip sacrifice in four cases, bipolar coagulation with the intent to seal defect in three cases, and bipolar coagulation with the intent to sacrifice the ICA in one case. Intraoperative or immediate postoperative angiography was reported in 27 cases. CONCLUSIONS The incidence of reported cases of ICA injury during EES remains low. Left-sided injuries to the cavernous segment of the ICA occurred more frequently than injuries on the right. LEVEL OF EVIDENCE NA Laryngoscope, 126:582-590, 2016.
Collapse
Affiliation(s)
- Oliver Y Chin
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Ritam Ghosh
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Christina H Fang
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - James K Liu
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A.,Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey, U.S.A
| |
Collapse
|
23
|
Labib MA, Prevedello DM, Carrau R, Kerr EE, Naudy C, Abou Al-Shaar H, Corsten M, Kassam A. A Road Map to the Internal Carotid Artery in Expanded Endoscopic Endonasal Approaches to the Ventral Cranial Base. Oper Neurosurg (Hagerstown) 2014; 10 Suppl 3:448-71; discussion 471. [DOI: 10.1227/neu.0000000000000362] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches.
OBJECTIVE:
To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery.
METHODS:
Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed.
RESULTS:
Based on anatomic correlations, the ICA may be described as 6 distinct segments: (1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment.
CONCLUSION:
The proposed endoscopic classification outlines key anatomic reference points independent of the vessel's geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system.
Collapse
Affiliation(s)
- Mohamed A. Labib
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Ricardo Carrau
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University, Columbus, Ohio
| | | | | | - Hussam Abou Al-Shaar
- Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Martin Corsten
- Department of Otolaryngology, University of Ottawa, Ottawa, Ontario, Canada
| | - Amin Kassam
- Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| |
Collapse
|
24
|
Wewel J, Mangubat EZ, Muñoz L. Iatrogenic traumatic intracranial aneurysm after endoscopic sinus surgery. J Clin Neurosci 2014; 21:2072-6. [PMID: 25128281 DOI: 10.1016/j.jocn.2014.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 05/17/2014] [Indexed: 10/24/2022]
Abstract
Iatrogenic traumatic intracranial aneurysms are rare, but their clinical impact is significant secondary to their risk of intracranial hemorrhage and in their frequent complexity in management. We report an adult patient with a history of chronic sinusitis who, while undergoing elective endoscopic polypectomy, suffered an iatrogenic injury to an A2 segment branch of the left anterior cerebral artery, resulting in a pseudoaneurysm. Management included endovascular coiling and a bicoronal craniotomy approach, using a split-thickness cranial graft and abdominal fat graft to repair the associated left cribriform plate defect.
Collapse
Affiliation(s)
- Joshua Wewel
- Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA.
| | - Erwin Zeta Mangubat
- Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA
| | - Lorenzo Muñoz
- Rush Professional Office Building, 1725 W. Harrison Street, Suite 855, Chicago, IL 60612, USA
| |
Collapse
|
25
|
Griauzde J, Gemmete JJ, Pandey AS, McKean EL, Sullivan SE, Chaudhary N. Emergency reconstructive endovascular management of intraoperative complications involving the internal carotid artery from trans-sphenoidal surgery. J Neurointerv Surg 2014; 7:67-71. [PMID: 24408926 DOI: 10.1136/neurintsurg-2013-010878] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To report our experience with intraoperative complications involving the internal carotid artery (ICA) during trans-sphenoidal surgery and their outcome with reconstructive endovascular management. METHODS A retrospective review was conducted of patients with an ICA injury related to trans-sphenoidal surgery from 2000 to 2012. Demographic data, clinical charts, indications for treatment, radiographic images, lesion characteristics, operative notes, endovascular procedure notes and post-procedure hospital course were reviewed. RESULTS Three men and one woman of mean age of 52 years (range 33-74) were identified. The lesions included two macroadenomas, one meningioma and one chondrosarcoma. Risk factors for ICA rupture included two patients with carotid dehiscence, one with sphenoid septal attachment to the ICA, two with revision surgery, one with prior radiation to the tumor, one with bromocriptine treatment and two with acromegaly. In three patients, covered stent placement achieved hemostasis at the site of injury within the ICA. One patient developed delayed bleeding 6 h after covered stent placement and underwent successful endovascular occlusion of the ICA but died 6 days after the injury. The fourth patient had an intraoperative ICA stroke requiring suction thrombectomy, thrombolysis, stent placement and evacuation of an epidural hematoma. At 1-year follow-up, two patients had a modified Rankin score (mRS) and National Institute of Health Stroke Scale (NIHSS) score of 0; in the patient who had a stroke the mRS score was 1 and the NIHSS score 2. CONCLUSIONS Endovascular management with arterial reconstruction is helpful in the treatment of ICA injuries during trans-sphenoidal surgery.
Collapse
Affiliation(s)
- Julius Griauzde
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Division of NeuroInterventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA Cranial Base Surgery Program, Department of Otolaryngology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Division of NeuroInterventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Erin L McKean
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA Cranial Base Surgery Program, Department of Otolaryngology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Stephen E Sullivan
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA Cranial Base Surgery Program, Department of Otolaryngology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Division of NeuroInterventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| |
Collapse
|
26
|
Han S, Ding X, Tie X, Liu Y, Xia J, Yan A, Wu A. Endoscopic endonasal trans-sphenoidal approach for pituitary adenomas: is one nostril enough? Acta Neurochir (Wien) 2013; 155:1601-9. [PMID: 23736939 DOI: 10.1007/s00701-013-1788-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/23/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Over the past decade, the endoscopic endonasal trans-sphenoidal approach has been used to resect pituitary adenomas. However, in the use of this procedure, some research teams prefer a two-nostril method, whereas other groups are in favor of the one-nostril method. Here, we present a series of pituitary adenomas and try to confirm whether or not one nostril is enough for endoscopic resection of most pituitary adenomas. METHODS A total of 250 consecutive patients who underwent an endoscopic endonasal trans-sphenoidal approach were reviewed retrospectively, of which 200 were via the unilateral nostril (group 1) and 50 were via bilateral nostrils (group 2). Surgical and clinical outcomes were analyzed. RESULTS For microadenomas, intrasellar macroadenomas and macroadenomas with moderate extrasellar extension, the prevalence of gross total resection (GTR), hormonal outcome and visual improvement were similar between the two groups. The one-nostril group had better results for duration of surgery and blood loss, with fewer rhinological complications. However, for macroadenomas with extensive extrasellar invasion, GTR was obtained in two of seven patients in group 2 but none in group 1. CONCLUSION The one-nostril method, which is relatively fast and minimally invasive, is adequate for endoscopic resection of most pituitary adenomas with moderate extension.
Collapse
Affiliation(s)
- Sheng Han
- Department of Neurosurgery, The First Hospital of China Medical University, Nanjing Street 155, Heping District, Shenyang, 110001, China
| | | | | | | | | | | | | |
Collapse
|
27
|
Tuchman A, Khalessi AA, Attenello FJ, Amar AP, Zada G. Delayed cavernous carotid artery pseudoaneurysm caused by absorbable plate following transsphenoidal surgery: case report and review of the literature. J Neurol Surg Rep 2013; 74:10-6. [PMID: 23943714 PMCID: PMC3713556 DOI: 10.1055/s-0033-1338164] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 08/24/2012] [Indexed: 11/03/2022] Open
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.
Collapse
Affiliation(s)
- Alexander Tuchman
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | | | | | | | | |
Collapse
|
28
|
Berhouma M, Messerer M, Jouanneau E. Chirurgie endoscopique de l’hypophyse et de la base du crâne. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/s0246-0378(12)60162-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
29
|
Berhouma M, Messerer M, Jouanneau E. [Shifting paradigm in skull base surgery: Roots, current state of the art and future trends of endonasal endoscopic approaches]. Rev Neurol (Paris) 2011; 168:121-34. [PMID: 22104065 DOI: 10.1016/j.neurol.2011.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Revised: 05/05/2011] [Accepted: 07/22/2011] [Indexed: 02/07/2023]
Abstract
During the last two decades, endoscopic endonasal approach has completed the minimally invasive skull base surgery armamentarium. Endoscopic endonasal skull base surgery (EESBS) was initially developed in the field of pituitary adenomas, and gained an increasing place for the treatment of a wide variety of skull base pathologies, extending on the midline from crista galli process to the occipitocervical junction and laterally to the parasellar areas and petroclival apex. Until now, most studies are retrospective and lack sufficient methodological quality to confirm whether the endoscopic endonasal pituitary surgery has better results than the microsurgical trans-sphenoidal classical approach. The impressions of the expert teams show a trend toward better results for some pituitary adenomas with the endoscopic endonasal route, in terms of gross total resection rate and probably more comfortable postoperative course for the patient. Excepting intra- and suprasellar pituitary adenomas, EESBS seems useful for selected lesions extending onto the cavernous sinus and Meckel's cave but also for clival pathologies. Nevertheless, this infatuation toward endoscopic endonasal approaches has to be balanced with the critical issue of cerebrospinal fluid leaks, which constitutes actually the main limit of this approach. Through their experience and a review of the literature, the authors aim to present the state of the art of this approach as well as its limits.
Collapse
Affiliation(s)
- M Berhouma
- Unité de chirurgie de la base du crâne, service de neurochirurgie A, hôpital neurologique et neurochirurgical Pierre-Wertheimer, hospices civils de Lyon, 59, boulevard Pinel, 69394 Lyon cedex 03, France.
| | | | | |
Collapse
|
30
|
Abstract
Carotid artery injury during endonasal surgery is the most feared and catastrophic complication. Internal carotid artery injury is more frequent during skull base surgery, and risk factors include acromegaly, previous revision surgery, and prior radiotherapy and bromocriptine therapy. Nasal packing is frequently used to gain hemostasis, often resulting in vascular occlusion. Recent research recommends the crushed muscle patch treatment as an effect hemostat that maintains vascular patency. Endovascular techniques are recommended for vascular control and complication management. Coil or balloon embolization is preferred in patients with adequate collateral cerebral blood flow, and stent-graft placement or bypass surgery is indicated in those who do not.
Collapse
|
31
|
Ogawa Y, Nakagawa A, Takayama K, Tominaga T. Pulsed laser-induced liquid jet for skull base tumor removal with vascular preservation through the transsphenoidal approach: a clinical investigation. Acta Neurochir (Wien) 2011; 153:823-30. [PMID: 21229274 DOI: 10.1007/s00701-010-0925-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 12/14/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND The transsphenoidal approach has recently been used to treat complex lesions beyond the sella turcica, but the difficulties of dealing with small vessels, deep and narrow space, and working angle may limit the procedures. To overcome these problems, we have developed a pulsed laser-induced liquid jet (LILJ) system to dissect tumor tissue with preservation of fine blood vessels within deep and narrow working spaces and evaluated its utility and safety. METHODS The LILJ system was applied to 14 consecutive patients with uncharacteristically complex skull base tumor treated through the extended transsphenoidal approach. This system consists of a bayonet-shaped catheter incorporating a jet generator formed of stainless tube (external diameter 1.10 mm, internal diameter 0.78 mm), which was surrounded by a coaxial polytetrafluoroethylene 14-G equivalent suction tube to be able to incorporate into the confined working spaces. Minor modifications could be fitted for the catheter (15 to 18 cm length, straight or side flexion tip), and total weight was around 7 g. FINDINGS Precise dissection and mass reduction of the tumor were obtained in all cases except one recurrent case of chordoma with significant fibrosis due to radiation. Both small arteries and veins were preserved, allowing subsequent microsurgical devascularization. Intraoperative blood loss was minimal, and tumor removal rate was satisfactory after the introduction of the system. No complication was related to use of the LILJ system. CONCLUSION Although comparison between conventional surgical instruments is mandatory in the future, the present study suggests that the LILJ system can achieve safe and optimum removal of complex skull base tumor. Potential application for minimally invasive endoscopic system, as well as potentials for changing the design of the catheter in according to preference of surgeon with low cost, may give advantages over conventional surgical instruments.
Collapse
Affiliation(s)
- Yoshikazu Ogawa
- Department of Neurosurgery, Kohnan Hospital, Nagamachiminami, Taihaku-ku, Sendai, Miyagi, Japan.
| | | | | | | |
Collapse
|
32
|
McGrath BM, Maloney WJ, Wolfsberger S, Hill R, Massoud E, Imran SA, Clarke DB. Carotid artery visualization during anterior skull base surgery: a novel protocol for neuronavigation. Pituitary 2010; 13:215-22. [PMID: 20151209 DOI: 10.1007/s11102-010-0220-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Detailed knowledge of the vascular anatomy of the anterior skull base is critical to successful surgery in this area. Whereas conventional neuronavigational approaches combine MRI (+/- contrast) for tumor visualization and CT (+/- C) for bony and vascular anatomy, we describe the Canadian and Austrian experiences using a novel protocol integrating MR angiography (MRA) into surgical neuronavigation to provide superior visualization of the carotid arteries. The pre-operative imaging protocol employs a T1-weighted, 3D fast spoiled gradient echo MRI (+/- C) for soft tissue anatomy, a plain CT for bony anatomy, and a 3D time-of-flight MR angiography for carotid anatomy. The series are imported into the Medtronic StealthStation((R)) TREON((R)) Treatment Guidance System; during intra-operative neuronavigation, each series (MRI, CT, MRA) can be viewed individually, or layered and viewed as a composite image. Our protocol has important advantages. First, it provides detailed tissue, tumor, vascular and bony anatomy. Second, a contrast CT is not necessary; this is important, as numerous reports have highlighted the nephrotoxic nature of radiographic contrast material. Third, visualization of the carotid system is superior than can be obtained from CT angiography. We use this unique imaging protocol routinely for our endoscopic transsphenoidal surgeries to provide superior visualization of the carotid arteries during anterior skull base surgery.
Collapse
Affiliation(s)
- Brent M McGrath
- Department of Surgery (Neurosurgery), Dalhousie University, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | | | | | | | | | | | | |
Collapse
|
33
|
Wang J, Bidari S, Inoue K, Yang H, Rhoton A. Extensions of the sphenoid sinus: a new classification. Neurosurgery 2010; 66:797-816. [PMID: 20305499 DOI: 10.1227/01.neu.0000367619.24800.b1] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The transsphenoidal approach has been extended in recent years from tumors of the sellar region to lesions involving other areas bordering the sphenoid sinus including the cavernous sinus, Meckel's cave, middle cranial fossa, planum sphenoidal, suprasellar region, and clivus. The goal of this study was to examine various pneumatized extensions of the sphenoid sinus that may facilitate extended approaches directed through the sinus. METHODS The sphenoid sinus and its surrounding structures were examined in 18 cadaver heads, and the results were correlated with the findings from 100 computed tomography images of the sinus. The sellar type of the sphenoid sinus in which the pneumatization extended beyond the anterior sellar wall was further classified according to the various extensions of the sinus. RESULTS The sellar type of the sphenoid sinus was classified into the following 6 basic types based on the direction of pneumatization: sphenoid body, lateral, clival, lesser wing, anterior, and combined. The recesses and prominences, formed by pneumatization of the sinus, act as "windows" opening from the sinus in different areas of the cranial base and may facilitate minimally invasive access to lesions in the corresponding areas. CONCLUSION The variations in the extensions of pneumatization of the sphenoid sinus may facilitate entry into areas bordering the sphenoid sinus and play a role in the selection of a surgical approach to lesions bordering the sinus.
Collapse
Affiliation(s)
- Jian Wang
- Department of Neurosurgery University of Florida Gainesville, Florida, USA
| | | | | | | | | |
Collapse
|
34
|
Massive epistaxis resulting from an intracavernous internal carotid artery traumatic pseudoaneurysm: complete resolution with overlapping uncovered stents. Acta Neurochir (Wien) 2009; 151:1681-4. [PMID: 19350203 DOI: 10.1007/s00701-009-0294-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 03/19/2009] [Indexed: 01/01/2023]
Abstract
Blunt traumatic injuries of the intracranial carotid arteries can result in pseudoaneurysm formation. A pseudoaneurysm of the intracavernous carotid artery may rupture into the cavernous sinus, causing life-threatening epistaxis. We report a case of intracavernous traumatic psedoaneurysm presenting with delayed massive epistaxis. The endovascular treatment with overlapping self-expanding stents achieved complete exclusion of the pseudoaneurysm with preservation of the intracavernous carotid artery.
Collapse
|
35
|
Ebner FH, Kuerschner V, Dietz K, Bueltmann E, Naegele T, Honegger J. Reduced intercarotid artery distance in acromegaly: pathophysiologic considerations and implications for transsphenoidal surgery. ACTA ACUST UNITED AC 2009; 72:456-60; discussion 460. [DOI: 10.1016/j.surneu.2009.07.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 07/03/2009] [Indexed: 11/24/2022]
|
36
|
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. ACTA ACUST UNITED AC 2009; 72:741-6. [PMID: 19604552 DOI: 10.1016/j.surneu.2009.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Accepted: 05/04/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND An internal carotid artery (ICA) injury is an uncommon but potentially fatal complication of transsphenoidal surgery. CASE DESCRIPTION We report a 61-year-old male patient with a right cavernous ICA injury sustained during transsphenoidal surgery and who underwent endovascular Stent graft placement. The ICA trapping was not indicated because of the absence of the left A1 on preoperative magnetic resonance angiography. During Stent graft placement, the ICA wall could not be completely fit with a stent due to its stiff nature and the carotid curve. The gap between the stent and the ICA wall was filled using a coiling procedure on the first postoperative day. CONCLUSIONS Endovascular Stent graft placement for posttranssphenoidal carotid artery injury is a useful technical adjunct to the management strategy and has the potential to minimize the risk of having to sacrifice the ICA. In cases of incomplete reconstruction of the Stent graft placement due to its stiff nature and the carotid curve, an additional coiling procedure could be helpful to obliterate the gap between the stent and the ICA wall. To avoid carotid injury during transsphenoidal surgery, careful preoperative evaluation of vascular structures and meticulous surgical technique are necessary.
Collapse
Affiliation(s)
- Young Seok Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
| | | | | | | | | |
Collapse
|
37
|
|
38
|
Dusick JR, Esposito F, Malkasian D, Kelly DF. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 2007; 60:322-8; discussion 328-9. [PMID: 17415170 DOI: 10.1227/01.neu.0000255408.84269.a8] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Internal carotid artery (ICA) injury during sellar dural opening is a potentially catastrophic complication of transsphenoidal surgery. We describe two ICA injuries that occurred early in our endonasal transsphenoidal experience. We then describe our subsequent protocol to prevent this complication in which we use the Doppler probe for carotid localization and micro-hook blades for lateral dural opening. METHODS All patients undergoing endonasal tumor removal were analyzed since beginning this approach in 1998. Of 631 procedures (585 patients), three patients sustained an ICA injury. RESULTS In the first 114 procedures (105 patients) in which the Doppler probe was not used and hook blades were used infrequently, two (1.8%) ICA injuries occurred. In both cases, a right nostril approach was used and the left ICA was punctured on dural opening with a straight scalpel; both patients recovered without neurological sequelae. In the subsequent 517 procedures in which the Doppler probe and hook blades were used in all cases, one (0.19%) probable ICA injury occurred during an attempted removal of a cavernous sinus schwannoma, although there was no angiographic evidence of vascular injury. There were no ICA or other intracranial vascular injuries in the last 510 procedures for tumors not solely confined to the cavernous sinus. CONCLUSION Cavernous carotid localization with the Doppler probe before dural opening and angled hook blades for lateral dural opening can help minimize the risk of ICA injury and are recommended for all transsphenoidal operations. Because of the wider contralateral exposure provided by the endonasal approach, the ICA contralateral to the nostril of approach is at higher risk of injury on dural opening.
Collapse
Affiliation(s)
- Joshua R Dusick
- Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | | | | | | |
Collapse
|
39
|
Wolfsberger S, Neubauer A, Bühler K, Wegenkittl R, Czech T, Gentzsch S, Böcher-Schwarz HG, Knosp E. ADVANCED VIRTUAL ENDOSCOPY FORENDOSCOPIC TRANSSPHENOIDAL PITUITARY SURGERY. Neurosurgery 2006; 59:1001-9; discussion 1009-10. [PMID: 17143234 DOI: 10.1227/01.neu.0000245594.61828.41] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Abstract
OBJECTIVE
Virtual endoscopy (vE) is the navigation of a camera through a virtual anatomical space that is computationally reconstructed from radiological image data. Inside this three-dimensional space, arbitrary movements and adaptations of viewing parameters are possible. Thereby, vE can be used for noninvasive diagnostic purposes and for simulation of surgical tasks. This article describes the development of an advanced system of vE for endoscopic transsphenoidal pituitary surgery and its application to teaching, training, and in the routine clinical setting.
METHODS
The vE system was applied to a series of 35 patients with pituitary pathology (32 adenomas, three Rathke's cleft cysts) operated endoscopically via the transsphenoidal route at the Department of Neurosurgery of the Medical University Vienna between 2004 and 2006.
RESULTS
The virtual endoscopic images correlated well with the intraoperative view. For the transsphenoidal approach, vE improved intraoperative orientation by depicting anatomical landmarks and variations. For planning a safe and tailored opening of the sellar floor, transparent visualization of the pituitary adenoma and the normal gland in relation to the internal carotid arteries was useful.
CONCLUSION
According to our experience, vE can be a valuable tool for endoscopic transsphenoidal pituitary surgery for training purposes and preoperative planning. For the novice, it can act as a simulator for endoscopic anatomy and for training surgical tasks. For the experienced pituitary surgeon, vE can depict the individual patient's anatomy, and may, therefore, improve intraoperative orientation. By prospectively visualizing unpredictable anatomical variations, vE may increase the safety of this surgical procedure.
Collapse
Affiliation(s)
- Stefan Wolfsberger
- Department of Neurosurgery, Medical University Vienna, General Hospital (AKH), Waehringer Guertel 18-20, A-1097 Vienna, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Schubert A, Deogaonkar A, Lotto M, Niezgoda J, Luciano M. Anesthesia for Minimally Invasive Cranial and Spinal Surgery. J Neurosurg Anesthesiol 2006; 18:47-56. [PMID: 16369140 DOI: 10.1097/01.ana.0000189993.14862.d1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The field of minimally invasive neurosurgery has evolved rapidly in its indications and applications over the last few years. New, less invasive techniques with low morbidity and virtually no mortality are replacing conventional neurosurgical procedures. Providing anesthesia for these procedures differs in many ways from conventional neurosurgical operations. Anesthesiologists are faced with the perioperative requirements and risks of newly developed procedures. This review calls attention to the anesthetic issues in various minimally invasive neurosurgical procedures for cranial and spinal indications. Among the procedures specifically discussed are endoscopic third ventriculostomy, endoscopic transsphenoidal hypophysectomy, endoscopic strip craniectomy, deep brain stimulation, video-assisted thorascopic surgery, vertebroplasty and kyphoplasty, cervical discectomy and foraminectomy, and laparoscopically assisted lumbar spine surgery.
Collapse
Affiliation(s)
- Armin Schubert
- Department of General Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195, USA.
| | | | | | | | | |
Collapse
|
41
|
Inamasu J, Guiot BH. Iatrogenic carotid artery injury in neurosurgery. Neurosurg Rev 2005; 28:239-47; discussion 248. [PMID: 16091974 DOI: 10.1007/s10143-005-0412-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Revised: 06/08/2005] [Accepted: 07/15/2005] [Indexed: 11/25/2022]
Abstract
Iatrogenic carotid artery injury (CAI) results from various neurosurgical procedures. A review of the literature was conducted to provide an update on the management of this potentially devastating complication. Iatrogenic CAIs are categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., anterior cervical spine surgery, central venous catheterization, chemical substances, chiropractic manipulation, diagnostic cerebral angiography, middle-ear surgery, percutaneous procedures for trigeminal neuralgia, radiation therapy, skull-base surgery, tracheostomy, and transsphenoidal surgery. The incidence, mechanisms of injury, diagnostic imaging modalities, and reparative procedures are discussed for each procedure. Iatrogenic CAI may be more prevalent than had previously been thought, mostly because of a heightened awareness on the part of physicians and the earlier detection of asymptomatic patients owing to sophisticated and less-invasive imaging modalities. Prevention is the best treatment for every iatrogenic injury, and it is expected that further accumulation of experience with and knowledge of iatrogenic CAI will result in further reduction of this complication. Although some CAIs, such as radiation-induced carotid artery stenosis, may not be preventable, earlier intervention before the patient becomes symptomatic may favorably alter the prognosis. Following the rapid development of endovascular techniques in recent years, surgically inaccessible lesions can be treated in a more reliable and safe manner than before.
Collapse
Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, University of South Florida College of Medicine, Room 730, Harbourside Medical Tower, 4 Columbia Dr., Tampa, FL 33606, USA.
| | | |
Collapse
|
42
|
Cappabianca P, Cavallo LM, Esposito F, Valente V, de Divitiis E. Sellar Repair in Endoscopic Endonasal Transsphenoidal Surgery: Results of 170 Cases. Neurosurgery 2002. [DOI: 10.1227/01.neu.0000309112.17087.28] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Paolo Cappabianca
- Department of Neurological Sciences, Division of Neurosurgery, “Federico II” University, Naples, Italy
| | - Luigi Maria Cavallo
- Department of Neurological Sciences, Division of Neurosurgery, “Federico II” University, Naples, Italy
| | - Felice Esposito
- Department of Neurological Sciences, Division of Neurosurgery, “Federico II” University, Naples, Italy
| | - Vinicio Valente
- Division of Neurosurgery, Ospedale Civile dell'Annunziata, Cosenza, Italy
| | - Enrico de Divitiis
- Department of Neurological Sciences, Division of Neurosurgery, “Federico II” University, Naples, Italy
| |
Collapse
|
43
|
|
44
|
de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic transsphenoidal approach: adaptability of the procedure to different sellar lesions. Neurosurgery 2002; 51:699-705; discussion 705-7. [PMID: 12188948 DOI: 10.1097/00006123-200209000-00016] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2001] [Accepted: 04/29/2002] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To demonstrate the flexibility of the endoscopic transsphenoidal approach, with respect to nasal and paranasal anatomic features and the extension of different sellar lesions, for customization of the procedure for specific conditions. METHODS In 16 of 170 consecutive endoscopic transsphenoidal operations, some modifications of the standard approach were adopted to optimize surgical removal of different lesions. These modifications consisted of a hemisphenoidotomy, a partial ethmoidectomy, extended sellar floor opening toward the planum sphenoidale or the clivus, enlarged opening of the sphenoid ostium area with ipsilateral removal of the superior turbinate, and a bilateral approach. RESULTS The endoscopic endonasal procedure is easily adaptable to different specific conditions, with slight changes in the standard approach (more or less invasive). Therefore, this surgical procedure is satisfactory for different lesion locations and for the nasal and paranasal sinus anatomic features of individual patients. CONCLUSION The endoscopic surgical route should be tailored to different sellar lesions, and some modifications of the procedure are recommended in selected cases.
Collapse
Affiliation(s)
- Enrico de Divitiis
- Division of Neurosurgery, Department of Neurological Sciences, Federico II University of Naples, Naples, Italy
| | | | | |
Collapse
|
45
|
de Divitiis E, Cappabianca P, Cavallo LM. Endoscopic Transsphenoidal Approach: Adaptability of the Procedure to Different Sellar Lesions. Neurosurgery 2002. [DOI: 10.1227/00006123-200209000-00016] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
46
|
Cappabianca P, Cavallo LM, Colao A, de Divitiis E. Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 2002; 97:293-8. [PMID: 12186456 DOI: 10.3171/jns.2002.97.2.0293] [Citation(s) in RCA: 326] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT To assess postoperative complications related to the surgical procedure, a retrospective analysis was conducted in a series of 146 consecutively treated patients who underwent an endoscopic endonasal transsphenoidal approach to the sellar region for resection of pituitary adenomas between January 1997 and July 2001. METHODS Complications were divided into groups (nasofacial, sphenoid sinus, sella turcica, supra or parasellar, and endocrine complications) according to the anatomical structures and the systems involved. Overall, a decreased incidence of complications has been observed, compared with large historical series of the traditional microsurgical transsphenoidal approach, likely because of the overview inside the anatomy facilitated by the endoscope, and the decreased surgical trauma. CONCLUSIONS Transsphenoidal surgery, either microscopic or endoscopic, is a safe procedure in experienced hands, but serious complications still occur and must be reduced as much as possible. Additional improvement can be expected with greater experience and new technical developments. A coordinated team effort with other dedicated colleagues from different specialties is advised.
Collapse
Affiliation(s)
- Paolo Cappabianca
- Department of Neurological Sciences, Federico II University, Naples, Italy.
| | | | | | | |
Collapse
|
47
|
Oran I, Parildar M, Dalbasti T, Memis A, Ozdamar N. Intradural Aneurysm Caused by Arterial Injury during Surgery: Treatment with Coil Embolization. Interv Neuroradiol 2002; 7:353-6. [PMID: 20663370 DOI: 10.1177/159101990100700413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2001] [Accepted: 10/25/2001] [Indexed: 11/15/2022] Open
Abstract
SUMMARY We described a patient with subarachnoid hemorrhage due to a ruptured intradural aneurysm caused by arterial injury during surgery and severe symptomatic vasospasm. The iatrogenic posttraumatic aneurysm was occluded by using GDC with preservation of parent artery followed by intraarterial infusion of papaverine to treat vasospasm as an one-stage procedure. This resulted in significant angiographic resolution of the vasospasm and the patient's clinical outcome was excellent. Endovascular approach to posttraumatic intracranial aneurysms and endosaccular GDC embolization of aneurysm with concomitant intraarterial papaverine infusion to treat vasospasm are discussed.
Collapse
Affiliation(s)
- I Oran
- Ege University Medical School, Department of Radiology, Izmir; Turkey -
| | | | | | | | | |
Collapse
|