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Ghorbani M, Griessenauer CJ, Shojaei H, Wipplinger C, Hejazian E. Endovascular reconstruction of iatrogenic internal carotid artery injury following endonasal surgery: a systematic review. Neurosurg Rev 2020; 44:1797-1804. [PMID: 32860104 DOI: 10.1007/s10143-020-01379-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/30/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
The objective of this study is to provide an update on endovascular treatments for iatrogenic internal carotid artery (ICA) injuries following endonasal surgery. A systematic review of the literature was performed by using Medline, Cochrane library, and Scopus from 1999 to 2019. We used a combination of the MeSH terms "internal carotid artery," "iatrogenic disease," and "endovascular procedure." Twenty-six articles including 46 patients were identified for in this systematic review. The mean age of the patients was 49 years (CI: ± 4.2). The most common site of ICA injury was in cavernous segment (18 patients; 39%). The most common type of iatrogenic ICA injury was a traumatic pseudoaneurysm documented in 28 patients (60%). Endoluminal reconstruction was performed using covered stents in 28 patients, the Pipeline embolization device (PED) in 13 patients, the Surpass flow diverter device in three, the SILK flow diverter in one, and one case was treated using a combined approach of a covered stent and a PED. Flow diversion and covered stents resulted in a good clinical outcome in 94% and 89% of patients, respectively. This difference did not reach statistical significance (p = 1.0). Even though this systematic review was limited due to articles of small sample sizes and considerable heterogeneity, the results indicate that flow diverting devices and covered stents are good therapeutic options for endoluminal reconstruction of iatrogenic ICA injuries following endonasal surgery.
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Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Hamidreza Shojaei
- Department of Neurosurgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
| | | | - Ebrahim Hejazian
- Department of Neurosurgery, Babol University of Medical Sciences, Babol, Mazandaran, Iran
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Babgi M, Alsaleh S, Babgi Y, Baeesa S, Ajlan A. Intracranial Intradural Vascular Injury during Endoscopic Endonasal Transsphenoidal Surgery: A Case Report and Literature Review. J Neurol Surg Rep 2020; 81:e52-e58. [PMID: 32983828 PMCID: PMC7515681 DOI: 10.1055/s-0040-1717056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/25/2020] [Indexed: 10/25/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammed Babgi
- Department of Surgery, Division of Neurosurgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Saad Alsaleh
- Department of Otolaryngology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yaser Babgi
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saleh Baeesa
- Department of Surgery, Division of Neurosurgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Abdulrazag Ajlan
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Wang C, Zhang Y, Wang J, Ni S. Anterior Cerebral Artery Rupture During Extended Endoscopic Endonasal Transsphenoidal Approach for Severely Calcified Craniopharyngioma. World Neurosurg 2019; 126:537-540. [PMID: 30844531 DOI: 10.1016/j.wneu.2019.02.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND This report discusses the risks and complications of using the extended endoscopic endonasal transsphenoidal approach (EEETA) in a special craniopharyngioma case to caution neurosurgeons. CASE DESCRIPTION A 38-year-old woman with craniopharyngioma underwent EEETA surgery. Her anterior cerebral artery was punctured intraoperatively and clipped using an aneurysm clip through the nose in an emergency procedure. CONCLUSIONS The coexistence of severe calcified craniopharyngiomas, especially with sharp calcified spurs, a narrow distance between the anterior communicating artery and the planum sphenoidale, and a narrow distance between the bilateral internal carotid arteries is a significant warning signal during EEETA for craniopharyngiomas. In this circumstance, it may be preferable to use open microsurgical approaches. If the anterior communicating artery or anterior cerebral artery is punctured during EEETA, another method is available to fix the problem using an aneurysm clip through the nose, and not only endovascular embolization.
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Affiliation(s)
- Chuanwei Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong Province, China; Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong Province, China
| | - Yulin Zhang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong Province, China; Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong Province, China
| | - Jiangang Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong Province, China; Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong Province, China
| | - Shilei Ni
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, Shandong Province, China; Shandong Key Laboratory of Brain Function Remodeling, Jinan, Shandong Province, China.
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Khachatryan T, Khachatryan M, Fanarjyan R, Grigoryan M, Grigorian A. Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report. Surg Neurol Int 2018. [PMID: 29527388 PMCID: PMC5838828 DOI: 10.4103/sni.sni_317_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications. Case Description We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention. Conclusions This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.
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Affiliation(s)
| | - Marina Khachatryan
- Department of Neurosurgery, Yerevan State Medical University, Yerevan, Armenia
| | - Ruben Fanarjyan
- Department of Neurosurgery, Yerevan State Medical University, Yerevan, Armenia
| | - Mikayel Grigoryan
- Glendale Adventist Comprehensive Stroke Center, Los Angeles, California, USA
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Manjila S, Singh G, Ndubuizu O, Jones Z, Hsu DP, Cohen AR. Endovascular plug for internal carotid artery occlusion in the management of a cavernous pseudoaneurysm with bifrontal subdural empyema: technical note. J Neurosurg Pediatr 2017. [PMID: 28621574 DOI: 10.3171/2017.3.peds16370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors demonstrate the use of an endovascular plug in securing a carotid artery pseudoaneurysm in an emergent setting requiring craniotomy for a concurrent subdural empyema. They describe the case of a 14-year-old boy with sinusitis and bifrontal subdural empyema who underwent transsphenoidal exploration at an outside hospital. An injury to the right cavernous segment of the ICA caused torrential epistaxis. Bleeding was successfully controlled by inflating a Foley balloon catheter within the sphenoid sinus, and the patient was transferred to the authors' institution. Emergent angiography showed a dissection of the right cavernous carotid artery, with a large pseudoaneurysm projecting into the sphenoid sinus at the site of arterial injury. The right internal carotid artery was obliterated using pushable coils distally and an endovascular plug proximally. The endovascular plug enabled the authors to successfully exclude the pseudoaneurysm from the circulation. The patient subsequently underwent an emergent bifrontal craniotomy for evacuation of a left frontotemporal subdural empyema and exenteration of both frontal sinuses. He made a complete neurological recovery. Endovascular large-vessel sacrifice, obviating the need for numerous coils and antiplatelet therapy, has a role in the setting of selected acute neurosurgical emergencies necessitating craniotomy. The endovascular plug is a useful adjunct in such circumstances as the device can be deployed rapidly, safely, and effectively.
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Affiliation(s)
- Sunil Manjila
- Division of Pediatric Neurosurgery, Rainbow Babies and Children's Hospital, Department of Neurological Surgery, The Neurological Institute, University Hospitals Case Medical Center
| | - Gagandeep Singh
- Division of Interventional Neuroradiology, Department of Radiology, University Hospitals Case Medical Center, Cleveland
| | - Obinna Ndubuizu
- Division of Pediatric Neurosurgery, Rainbow Babies and Children's Hospital, Department of Neurological Surgery, The Neurological Institute, University Hospitals Case Medical Center
| | - Zoe Jones
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio
| | - Daniel P Hsu
- Kaiser Permanente Neuroscience Center, Redwood City, California; and
| | - Alan R Cohen
- Division of Pediatric Neurosurgery, Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland
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Almefty R, Dunn IF, Aziz-Sultan MA, Al-Mefty O. Delayed Carotid Pseudoaneurysms from Iatrogenic Clival Meningeal Branches Avulsion: Recognition and Proposed Management. World Neurosurg 2017; 104:736-744. [PMID: 28300709 DOI: 10.1016/j.wneu.2017.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/03/2017] [Accepted: 03/04/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Carotid injury during anterior skull base approaches is promptly recognizable and mandates immediate treatment; likewise, development of pseudoaneurysms after such injuries is anticipated and managed. METHODS We report here on the delayed development of a pseudoaneurysm as the result of avulsion of clival meningeal arteries that manifests as unalarming intraoperative bleeding. RESULTS AND CONCLUSIONS The bleeding is brisk and arterial but easily controlled. Immediate postoperative angiography is negative, necessitating repeated angiography to depict the delayed formation. It is best treated by endovascular means that maintains patency of the carotid artery, calling for the development of a suitable device that obliterates the opening of the pseudoaneurysm while maintaining carotid flow that is deployable in the tortuous carotid artery.
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Affiliation(s)
- Rami Almefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
| | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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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: 53] [Impact Index Per Article: 6.6] [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.
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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
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Tantongtip D, Fratianni A, Jenkner J, Arnold S, Spetzger U. Surgical Treatment of Inadvertent Internal Carotid Artery Lesion by Extraintracranial High-flow Bypass. A Case Report and Review of the Literature. J Neurol Surg Rep 2015; 76:e100-4. [PMID: 26251782 PMCID: PMC4520998 DOI: 10.1055/s-0035-1551670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 01/07/2015] [Indexed: 11/16/2022] Open
Abstract
Internal carotid artery (ICA) injury following transsphenoidal surgery is a rare but potentially fatal complication. Usually, endovascular occlusion of the ICA or stent graft placement is the treatment of these vascular complications described in literature. We present a case of ICA perforation during transsphenoidal surgery in a patient with limited collateral cerebral blood flow and with ectasia of the ICA that rule out an endovascular treatment. We report the surgical revascularization via high-flow extra-intracranial radial artery bypass and consicutive artery ligation.
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Affiliation(s)
- Dilok Tantongtip
- Department of Neurosurgery, Thammasat University, Pathum Thani, Thailand
| | - Alessia Fratianni
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Jost Jenkner
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Sebastian Arnold
- Department of Radiology, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Uwe Spetzger
- Department of Neurosurgery, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
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Kim BM, Jeon P, Kim DJ, Kim DI, Suh SH, Park KY. Jostent covered stent placement for emergency reconstruction of a ruptured internal carotid artery during or after transsphenoidal surgery. J Neurosurg 2014; 122:1223-8. [PMID: 25415067 DOI: 10.3171/2014.10.jns14328] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Internal carotid artery (ICA) rupture during transsphenoidal surgery (TSS) is an extremely difficult complication to treat. This study aimed to evaluate the immediate and long-term outcomes of covered stent placement for emergency reconstruction of ruptured ICAs during or after TSS. METHODS Seven patients underwent covered stent placement for emergency reconstruction of a ruptured ICA during or after TSS. The safety and effectiveness of covered stent placement for emergency reconstruction of ruptured ICAs were retrospectively analyzed. RESULTS Pretreatment angiography showed active bleeding in 6 patients (5 intraoperative and 1 postoperative) and a pseudoaneurysm in 1 patient. Of the 6 patients with active bleeding, 5 were treated with a successive operation to control active bleeding. The other patient was treated just after cardiopulmonary resuscitation due to massive nasal bleeding 20 days after revision of TSS. All active bleeding was controlled immediately after covered stent insertion in these 6 patients. One patient showed a gap between the covered stent and ICA wall without active bleeding 30 minutes after glycoprotein IIb/IIIa inhibitor administration due to in-stent thrombosis. The gap was occluded with coil embolization after completion of the temporarily suspended TSS. The seventh patient, whose ICA tear was treated with surgical suture, underwent covered stent placement for a pseudoaneurysm detected on postoperative Day 2. During a mean follow-up period of 46 months (range 12-85 months), all patients had excellent outcomes (modified Rankin Scale score of 0). All the stented ICAs were patent on vascular imaging follow-up at a mean of 34 months (range 12-85 months). CONCLUSIONS Covered stents appear to be a safe and effective option for emergency reconstruction of ruptured ICAs during or after TSS.
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Mortimer AM, Klimczak K, Nelson RJ, Renowden SA. Endovascular Management of Cavernous Internal Carotid Artery Pseudoaneurysms Following Transsphenoidal Surgery: A Report of Two Cases and Review of the Literature. Clin Neuroradiol 2014; 25:295-300. [PMID: 25139269 DOI: 10.1007/s00062-014-0332-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/04/2014] [Indexed: 11/26/2022]
Affiliation(s)
- A M Mortimer
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, Bristol, Southmead Road, UK,
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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.
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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
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Endovascular management of postoperative pseudoaneurysms of the external carotid artery. J Clin Neurosci 2012; 19:649-54. [PMID: 22502912 DOI: 10.1016/j.jocn.2011.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 11/03/2011] [Indexed: 11/22/2022]
Abstract
Hemorrhage secondary to postoperative pseudoaneurysm is a rare event, but may complicate the clinical course of straightforward and common interventions such as sinonasal procedures, tonsillectomy, and maxillofacial and plastic surgeries. We report our experience with the endovascular management of iatrogenic pseudoaneurysm in eight patients who had undergone recent craniomaxillofacial surgery. Computed tomography (CT), including CT-angiography, detected only three of the eight lesions. In all patients, endovascular embolization achieved successful occlusion of the pseudoaneurysm without local or general procedure-related complications. Immediate proximal arterial occlusion with detachable coils was performed in every case, and pseudoaneurysm coiling was performed in three cases presenting with active hemorrhage. Endovascular therapy proved to be safe and effective in the management of postoperative pseudoaneurysms. Surgeons involved in the craniomaxillofacial procedures should be aware of this complication and its management.
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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.
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