Surgical treatment of a ruptured internal carotid artery pseudoaneurysm following transsphenoidal surgery

Iatrogenic pseudoaneurysm after surgery: Stay away from the evil. Case report and review of the literature

BACKGROUND

Intracranial pseudoaneurysms are rare and account for less than 2% of all intracranial aneurysms. They most frequently occur after head injury, but they also can be caused by iatrogenic arterial injury during neurosurgical or ENT procedures. No clear guidelines are established concerning the treatment and surveillance of such aneurysms.

METHODS

In this article, we present 2 cases of iatrogenic pseudoaneurysms treated conservatively and we propose a review of literature of the management and outcome of intracranial iatrogenic pseudoaneurysms.

CASE REPORT AND RESULTS

The first case is one during a transcranial approach and the second one during a transsphenoidal approach, that were both conservatively treated with a close follow-up and a spontaneous healing of the aneurysm.

CONCLUSION

Endovascular treatment or surgical clipping are 2 valid therapeutic options in iatrogenic pseudoaneurysms, which should be preferred when feasible with a reasonable risk. In contrast, in case of a small pseudoaneurysm, important risk and complex procedures, conservative treatment with a close follow-up appears to be a valuable alternative.

Beware of epistaxis: fatal pseudoaneurysm rupture 30 years after treatment of acromegaly

We present a fatal complication of treatment in a patient with early-onset acromegaly, treated with two transsphenoidal operations, radiotherapy, radiosurgery and pegvisomant. He was diagnosed in his 30s, and controlled from his 40s, with stable residual tumour within the left cavernous sinus. In his 60s, 30 years after surgery/radiotherapy and 14 years after radiosurgery, he developed recurrent episodes of mild epistaxis. A week later, he presented at his local hospital's emergency department with severe epistaxis and altered consciousness. He was diagnosed with a ruptured internal carotid artery (ICA) pseudoaneurysm, but unfortunately died before treatment could be attempted.ICA pseudoaneurysms are rare complications of surgery or radiotherapy and can present with several years of delay, often with epistaxis. This case highlights the importance of life-long monitoring in patients with previous pituitary interventions and early recognition of epistaxis as a herald sign of a potentially catastrophic event, thus leading to timely treatment.

Internal Carotid Artery Pseudoaneurysm After Transsphenoidal Pituitary Tumor Resection: A Case Report

Here, we present a case report on internal carotid artery pseudoaneurysm (ICAP) which highlights a rare but potentially life-threatening complication of transsphenoidal pituitary surgery. A 32-year-old male underwent resection of a pituitary tumor and developed a large cerebrospinal fluid (CSF) leak during surgery, which was reconstructed with a fat graft and nasoseptal flap. Postoperatively, he was recovering well and discharged without complications; however, eight days after surgery he returned with massive epistaxis and hematemesis. This was initially managed with endoscopic exploration, nasal packing, and transfusion of blood products. Imaging revealed a pseudoaneurysm on the right internal carotid artery. The patient was started on aspirin and clopidogrel, and a flow diverter stent was placed without complications. Our case emphasizes the importance of prompt recognition and management of vascular injuries such as an internal carotid pseudoaneurysm after transsphenoidal pituitary surgery to prevent catastrophic outcomes.