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Rupture from Cavernous Internal Carotid Artery Pseudoaneurysm 11 Years After Transsphenoidal Surgery

Tom Morrison

Background: Bioabsorbable plates are frequently
utilized in the repair of skull base defects following
transsphenoidal operations. Traumatic intracranial

pseudoaneurysms are a rare complication of trans-
sphenoidal surgery. To date, iatrogenic carotid pseu-
doaneurysm associated with the use of an absorb-
able 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 re-
construct the sellar floor. He experienced delayed

repeated epistaxis, followed by a right middle cere-
bral artery distribution embolic stroke. Computed to-
morgraphy (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 obliter-
ate the pseudoaneurysm, and the patient fully recov-
ered.

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, un-
less it is required to buttress a large skull base defect.

Short-segment embolization with stent coiling is the

preferred treatment option for carotid pseudoaneu-
rysms following transsphenoidal operations.

Keywords: cavernous, carotid, pseudoaneurysm, ar-
tery

Introduction: The transsphenoidal approach is the
most commonly utilized operation for the surgical

treatment of sellar lesions and is a relatively safe op-
eration in experienced centers.1 Following resection

of pituitary adenomas and other sellar tumors, many
surgeons utilize absorbable plates to reconstruct the
bony sellar floor to serve as a buttress for the sellar
contents and repair construct. Although usually safe,
vascular injury in conjunction with insertion of rigid

plates following sellar tumor resection has been de-
scribed once before.2

Common complications of transsphenoidal opera-
tions include endocrine abnormalities and cerebro-
spinal fluid (CSF) leaks.3 Vascular injury is a rare but

serious complication of transsphenoidal surgery en-
countered in 0.8 to 1.1% of cases, with an associated

mortality of nearly 30%.4,5,6 The majority of vascu-
lar injuries are identified at the time of surgery, usu-
ally resulting from direct injury to the internal carotid

artery during resection of tumor within the cavern-
ous sinus or upon opening of the dura, often result-
ing in profuse arterial hemorrhage.6,7,8,9 Other de-
scribed vascular complications include vasospasm,

carotid thrombosis, cavernous sinus thrombosis,

embolism, caroticocavernous fistula, or pseudoan-
eurysm.2,3,7,8,10,11,12,13,14,15,16,17,18,19

Postoperative carotid pseudoaneurysm, though rare,
represents a grave risk to the patient if unrecognized.

It may lead to delayed hemorrhagic or embolic com-
plications when the patient is no longer in a moni-
tored hospital setting. This case report highlights the

importance of rapid diagnosis and treatment of these

lesions. We present a rare case of delayed pseudo-
aneurysm and embolic stroke following erosion of a

rigid plate into the cavernous internal carotid artery.

Case Report: A 57-year-old man with a nonfunction-
al pituitary macroadenoma causing vision loss un-
derwent a gross total, endoscopic transsphenoidal

resection (Fig. 1). The tumor was invading the right
cavernous sinus wall. During the procedure to resect