Posterior Cerebral Artery Pseudoaneurysm, a Rare Complication of Pituitary Tumor Transsphenoidal Surgery: Case Report and Literature Review

Treatment of Traumatic Internal Carotid Artery Aneurysm by Flow-Diverter: A Single-Center Experience

AIM

Traumatic intracranial aneurysm (TICA) is a rare vascular lesion with various etiologies and a high mortality rate when diagnosed late. In this study, we present our cases of TICA, which we treated with flow-diverter stents due to different etiological factors.

METHODS

Clinical data were recorded for 8 patients: age, gender, etiological factors, aneurysm location, aneurysm type, rupture, main artery status, and postoperative complications.

RESULTS

75% (n:6) of the patients were male and 25% (n:2) female. Etiologically, there was intracranial tumor surgery in 3 cases (37.5%), fall from height in 2 (25%), road accident in 2 (25%), and blunt trauma in 1 (12.5%). Reconstruction used a flow-diverting stent in all cases. One patient experienced intraoperative iatrogenic rupture of the distal arterioles due to a microwire. Mean angiographic follow-up was 17.8 months (range, 6-32 months). During follow-up, none of the patients required renewed endovascular treatment.

CONCLUSION

Traumatic aneurysm is a vascular lesion with high mortality when diagnosed late. In case of suspected vascular injury after trauma or intracranial surgery, further evaluation should be performed without delay. TICA can be safely treated with flow-diverter stents, conserving the main artery.

Giant Prolactinoma Embedded by Pseudoaneurysm of the Cavernous Carotid Artery Treated with a Tailored Therapeutic Scheme

The coexistence of intracranial aneurysm (IA) is generally thought to be highest in patients with pituitary adenomas (PAs). Different mechanisms may play a role in aneurysm formation, but whether the PA contributes to aneurysm formation is still unclear. In the literature, there are numerous reported cases of this association; however, the analyses of the characteristics of PAs, aneurysms, and treatment management are rare and limited to a restricted number of case reports. We report a rare case of an embedded aneurysm in a macroprolactinoma treated with therapeutic management tailored to the clinical, neurological, and radiological characteristics of the patient. To select the best treatment, we reviewed the literature and reported the only cases in which the radiological characteristics of aneurysms, PAs, therapeutic management, and patient outcome are described. We aimed to understand what are the variables that determine the best therapeutic management with the best possible outcome. The presence of a large pseudoaneurysm of the internal carotid artery completely embedded in a giant macroprolactinoma is rare and needs a tailored treatment strategy. The importance of the preoperative knowledge of asymptomatic IA coexisting with PA can avoid accidental rupture of the aneurysm during surgical resection and may lead to planning the best treatment. A high degree of suspicion for an associated aneurysm is needed, and if magnetic resonance imaging shows some atypical features, digital subtraction angiography must be performed prior to contemplating any intervention to avoid iatrogenic aneurysmal rupture. Our multimodal approach with the first-line therapy of low-dose cabergoline to obtain prolactin normalization with minimum risks of aneurysms rupture and subsequent endovascular treatment with flow diverter has not been described elsewhere to our knowledge. In the cases, we suggest adopting a tailored low-dose cabergoline therapy scheme to avoid rupture during cytoreduction and initiate a close neuroradiological follow-up program.

Treatment of an anterior cerebral artery pseudoaneurysm secondary to a transsphenoidal surgery using stent-assisted coiling

Background:

Injury of the internal carotid artery (ICA) during transsphenoidal surgery (TSS) is a rare but critical complication. There are several reports on endovascular treatment of ICA injury during TSS. With the recent flourishing of extended TSS, injuries to the distal arteries such as the anterior cerebral artery (ACA) are more likely to occur.

Case Description:

In the present case, we report a pseudoaneurysm of the right ACA due to injury during extended TSS for aggressive prolactinoma. Due to the absence of collateral vessels, the pseudoaneurysm had to be obliterated while preserving the parent artery. Hence, we decided to treat the pseudoaneurysm using stent-assisted coiling (SAC). The pseudoaneurysm was completely obliterated and he was discharged without any complications.

Conclusion:

To the best of our knowledge, this is the first case in which an ACA pseudoaneurysm caused by injury during the TSS was treated with SAC and the parent artery was preserved.

Sellar Region Lesions and Intracranial Aneurysms in the Era of Endoscopic Endonasal Approach

In the clinical practice of neurosurgery, the endoscopic endonasal approach (EEA) has been the mainstream approach in the management of sellar region diseases. However, clinicians have come to realize that EEA procedure is associated with intraoperative hemorrhage. Due to the limited surgical field and poor proximal control under endoscope, massive hemorrhage always leads to severe complication or even perioperative death. Previously, intraoperative hemorrhage used to be attributed to endoscopic intervention of cavernous sinus or internal carotid artery, but our recent understanding of EEA indicated that preoperatively complicated intracranial aneurysms (IAs) may play a role. In this article, we retrospectively reviewed the baseline characteristics, treatment strategy, pathology, intraoperative findings, as well as radiological profiles of sellar region lesions complicated with IAs. With the focus put on the high comorbidity rate of sellar region lesions and IAs, we did further statistical analysis to sketch the outline of this coexisting circumstance and to emphasize the importance of computed tomography angiography (CTA) as routine EEA preoperative examination. Thorough patient-surgeon communication should be proceeded before the formulation of an individualized treatment strategy.

Intracranial Pseudoaneurysms: Evaluation and Management

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.

Intracranial Intradural Vascular Injury during Endoscopic Endonasal Transsphenoidal Surgery: A Case Report and Literature Review

Background  Transsphenoidal surgery (TSS) is a procedure for sellar or midline masses in the skull base. Among the reported complications are iatrogenic vascular injuries; that are rare, yet they carry devastating outcomes, with an incidence of injury between 0.34 and 2.6%. The cavernous internal carotid artery is the most commonly injured. However, intradural arterial injuries are much less reported with challenging management. We report a rare incident of intradural arterial injury during TSS, and we compared our management to the summarized few cases reported in the literature Case Report  We report a 43-year-old female who had a recurrent planum sphenoidal meningioma. She underwent trans-nasal transsphenoidal endoscopic resection that was complicated with intraoperative bleeding due to an injury to the anterior communicating artery that was challenging to control, resulted in a bilateral loss of flow in A1 segments of anterior cerebral artery and required endovascular management. The patient had a good recovery postoperatively without the typical picture of ACA syndrome. Conclusion  Intradural arterial injury is exceedingly rare in TSS, with no clear standard of care for the management. Collateral blood supply allows definitive management with minimal morbidity. Identifying the risk factors beforehand, as well as performing such cases in a well-resourced center, are crucial elements of safety.

Efficacy of transsphenoidal surgery for pituitary tumor: A protocol for systematic review

BACKGROUND

This systematic review aims to assess the efficacy and safety of transsphenoidal surgery (TPS) for patients with a pituitary tumor (PT).

METHODS

We will retrieve the following electronic databases for randomized controlled trials or case-control studies to assess the effect and safety of TPS for PT: Cochrane Library, EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database. Each database will be retrieved from the inception to December 20, 2018. The entire process consists of the study selection, data collection, methodology quality assessment, data pooled, and meta-analysis performance. The methodology quality will be assessed by using Cochrane risk of bias tool. The data pooled and meta-analysis will be conducted by using RevMan 5.3 software.

RESULTS

This study will evaluate the efficacy and safety of TPS for PT. The primary outcome includes total tumor resection rate. The secondary outcomes consist of quality of life, total tumor resection rate, postoperative complication rate, and the rate of functional tumor hormone levels.

CONCLUSION

The expected results may provide up-to-date evidence of TPS for the treatment of PT.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42018120194.

Iatrogenic pseudoaneurysms associated with cerebrospinal fluid diversion procedures

Background:

Cerebrospinal fluid diversion procedures, including ventriculoperitoneal (VP) shunt and external ventricular drain insertion, are common treatments for hydrocephalus. Common complications include obstruction, infection, and hemorrhage. Pseudoaneurysm formation secondary to catheter insertion is a distinctly rare complication, and usually involves the anterior cerebral artery or branches of the external carotid artery (superficial temporal artery or middle meningeal artery).

Case Description:

We present the case of a fusiform pseudoaneurysm in a 36-year-old female, which arose from a branch of the middle cerebral artery following VP shunt insertion. Parenchymal and intraventricular hemorrhage at the catheter insertion site developed 15 days postoperatively. The VP shunt was removed, and the aneurysmal segment was coagulated and occluded. Use of a limited dural opening during ventricular catheter placement may have been a factor in pseudoaneurysm formation.

Conclusions:

The literature regarding this rare complication is reviewed. Careful consideration should be given to vascular anatomy when planning shunt insertions, and a cruciate dural opening for cortical visualization and coagulation may help avoid this complication. Prompt identification and management of iatrogenic pseudoaneurysms is essential to avoid re-bleeding and associated hemorrhagic complications.

Use of the Pipeline embolization device in the treatment of iatrogenic intracranial vascular injuries: a bi-institutional experience

OBJECTIVE Flow-diverting devices have been used for the treatment of complex intracranial vascular pathology with success, but the role of these devices in treating iatrogenic intracranial vascular injuries has yet to be clearly defined. Here, the authors report their bi-institutional experience with the use of the Pipeline embolization device (PED) for the treatment of iatrogenic intracranial vascular injuries. METHODS The authors reviewed a retrospective cohort of patients with iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2012 and 2016. Data collection included demographic data, indications for treatment, number and sizes of PEDs used, and immediate and follow-up angiographic and clinical outcomes. RESULTS Four patients with a mean age of 47.5 years (range 18-63 years) underwent PED placement for iatrogenic vessel injuries. In 3 patients, the intracranial internal carotid artery (ICA) was injured during transnasal tumor resection. In 1 patient, a basilar apex injury occurred during endoscopic third ventriculostomy. Three patients had a pseudoaneurysm as a result of vessel injury, and 1 patient had frank ICA laceration and extravasation. All 3 pseudoaneurysms were successfully treated with PED deployment. The ICA laceration was refractory to PED placement, and the vessel was subsequently occluded endovascularly. All 4 patients had a good clinical outcome (modified Rankin Scale score of 0 or 1). CONCLUSIONS The use of the PED is feasible in the management of iatrogenic pseudoaneurysms of the intracranial vasculature. In cases of frank vessel perforation, an alternative strategy such as covered stent placement should be considered. Endovascular or surgical vessel occlusion remains the definitive treatment in cases of refractory hemorrhage.

Endoscopic Endonasal Transclival Approach versus Dual Transorbital Port Technique for Clip Application to the Posterior Circulation: A Cadaveric Anatomical and Cerebral Circulation Simulation Study

Purpose  Simulation training offers a useful opportunity to appreciate vascular anatomy and develop the technical expertise required to clip intracranial aneurysms of the posterior circulation. Materials and Methods  In cadavers, a comparison was made between the endoscopic transclival approach (ETA) alone and a combined multiportal approach using the ETA and a transorbital precaruncular approach (TOPA) to evaluate degrees of freedom, angles of visualization, and ergonomics of aneurysm clip application to the posterior circulation depending on basilar apex position relative to the posterior clinoids. Results  ETA alone provided improved access to the posterior circulation when the basilar apex was high riding compared with the posterior clinoids. ETA + TOPA provided a significantly improved functional working area for instruments and visualization of the posterior circulation for a midlevel basilar apex. A single-shaft clip applier provided improved visualization and space for instruments. Proximal and distal vascular control and feasibility of aneurysmal clipping were demonstrated. Conclusions  TOPA is a medial orbital approach to the central skull base; a transorbital neuroendoscopic surgery approach. This anatomical simulation provides surgical teams an alternative to the ETA approach alone to address posterior circulation aneurysms, and a means to preoperatively prepare for intraoperative anatomical and surgical instrumentation challenges.