Reporte de casos
Revista Chilena de Neurocirugía 38 : 2012
Endovascular treatment of iatrogenic pseudoaneurysm
and delayed carotid-cavernous fistula following
trans-sphenoidal surgery
Tratamiento endovascular de pseudoaneurisma y fístula
carótida-cavernosa iatrogénica después de la cirugía
trans-esfenoidal
Mário Luiz Marques Conti1, Guilherme Brasileiro de Aguiar1, José Carlos Esteves Veiga1, Américo Rubens Leite dos Santos1,
Paulo Roberto Lazarini2, Maurício Jory1, Ricardo Hideo Tachibana3, José Guilherme Mendes Pereira Caldas.4
1 Department of Surgery, Division of Neurosurgery, Santa Casa Medical School, São Paulo, Brazil.
2 Otorhinolaryngology Department, Santa Casa Medical School, São Paulo, Brazil.
3 Medical student; Santa Casa Medical School, São Paulo, Brazil.
4 INRAD - Radiology Institute, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo,
Brazil.
Rev. Chil. Neurocirugía 38: 147 - 150, 2012
Resumen
Lesiones accidentales de la arteria carótida son complicaciones poco frecuentes de diversos procedimientos diagnósticos y
terapéuticos. Representan una condición grave y potencialmente mortal si el tratamiento no se realiza adecuadamente. Un
paciente de sexo femenino, 45 años de edad, que ingresó en el servicio de Otorrinolaringología con queja de la disminución de la
agudeza auditiva y acúfenos en el oído izquierdo. La resonancia magnética encefálica mostro una formación expansiva / infiltrativa
a comprometer desde la nasofaringe izquierda hasta la base del cráneo, con la participación de la arteria carótida interna (ACI) en
el mismo lado en su segmento petroso. Durante el procedimiento de biopsia, se produjo una laceración en la carótida derecha
intracavernosa con sangrado abundante. Se realizó un taponamiento local y el paciente fue remitido a la angiografía cerebral que
mostró un seudoaneurisma en la arteria carótida interna derecha en su segmento cavernoso. Después de una prueba de oclusión,
la ACI derecha fue ocluida por 2 globos. Tres semanas después, el estado del paciente mostró empeoramiento progresivo de
la agudeza visual, proptosis ocular, hiperemia conjuntival y la restricción del movimiento ocular en el ojo derecho. Una nueva
angiografía fue realizada y mostró la persistencia de la oclusión de la ACI en su origen y un seudoaneurisma asociado con fístula
carótido-cavernosa derecha, que se opacificado después de la inyección de contraste en la ACI izquierda, a través de la arteria
comunicante anterior. El paciente fue sometido a un nuevo tratamiento endovascular con resolución de la lesión. Laceración de
ACI durante la cirugía transesfenoidal es una complicación rara y potencialmente fatal. La prevención es el mejor tratamiento
para cualquier lesión accidental. La utilización de técnicas endovasculares ha permitido para el tratamiento satisfactorio de esta
condición.
Palabras clave: Lesiones de la arteria carótida, seudoaneurismas, fístula carótido-cavernosa, tratamiento endovascular.
Abstract
Accidental carotid artery lesions are uncommon complications from diverse diagnostic and therapeutic procedures. It represents
a grave and potentially lethal condition if treatment is not adequately performed. A female patient, 45 years old, who was admitted
to the Otolaryngology service complaining of diminished auditory acuity and tinnitus in the left ear. The encephalic magnetic
resonance imaging (MRI) showed an expansive/infiltrative formation compromising the left nasopharynx to the skull base, involving
the ipsilateral internal carotid artery (ICA) in its petrous segment. During the biopsy procedure, there was a right intracavernous
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Revista Chilena de Neurocirugía 38 : 2012
ICA laceration with copious bleeding. A local tamponade was performed and the patient was referred to cerebral angiography
(CAG), which showed a right ICA pseudoaneurysm in its intracavernous segment. After a balloon occlusion test, the right ICA
was occluded by 2 balloons. Three weeks after, the patient’s condition showed progressive worsening of visual acuity, occular
proptosis, conjuctival hyperemia and occular movement restriction in the right eye. A new CAG was performed and showed
persistence in the right ICA occlusion in its origin and an intracavernous pseudoaneurysm associated with ipsilateral carotidcavernous fistula, which became opacified after contrast injection in left ICA, through the anterior communicating artery. The
patient was submitted to a new endovascular treatment with lesion resolution. ICA laceration during transsphenoidal surgery is a
rare and potentially fatal complication. The prevention is the best treatment for any accidental lesion. Utilization of endovascular
techniques has allowed for satisfactory treatment of this condition.
Key words: Carotid Artery Injuries, Pseudoaneurysms, Carotid-Cavernous Sinus Fistula, Endovascular Treatment.
Introduction
Accidental lesions in the carotid artery
are uncommon complications from various procedures1. During transsphenoidal surgeries the internal carotid artery
(ICA) lesion constitutes a rare event, albeit grave and potentially lethal if treatment is not adequately performed1,2,3,4. It
may manifest itself in peri- or postoperative bleeding, formation of internal carotid artery pseudoaneurysm or carotidca-vernous fistula (CCF)2,3,4,5, necessitating prompt diagnosis and treatment.
This case study describes a case of
right ICA laceration with the formation
of a pseudoaneurysm, during a transsphenoidal surgery on a skull base tumor
which was treated with ICA occlusion. A
few days after the occlusion, the patient
presented with occular symptoms. The
cerebral angiography confirmed the right
carotid occlusion and showed an ipsilateral carotid-cavernous fistula which
opacified via the anterior communicating
artery (ACoA). The patient was submitted to a new endovascular treatment
with lesion resolution. Furthermore, we
made a brief revision of the literature.
Case report
This female patient, 45 years old, was
admitted to the Otolaryngology service
complaining of diminished auditory acuity and tinnitus in the left ear. An encephalic magnetic resonance imaging
(MRI) was performed which showed an
expansive/infiltrative formation, compromising the left nasopharynx to the skull
base, involving the ipsilateral internal
carotid artery in its petrous segment.
Transsphenoidal lesion biopsy was suggested.
During the procedure, there was a right
intracavernous ICA laceration with copi-
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Figure 1: A – Right internal carotid artery angiography (lateral view), showing a pseudoaneurysm in the
right intracavernous internal carotid artery (arrow). B and C - cerebral angiography of the left internal carotid
artery during the right ICA balloon occlusion test (frontal view), not showing delay in angiographic times. D –
placement of the balloons following the right ICA occlusion (lateral view). E – final angiographic control from
the right common carotid artery (lateral view), showing right internal carotid artery occlusion (arrowheads).
Reporte de casos
ous bleeding. A local tamponade was
performed and the patient was referred
to cerebral angiography (CAG), which
showed a right ICA pseudoaneurysm
in its intracavernous segment (Figure
1A). Following the occlusion test (Figure
1 B-C), the right ICA was occluded by
means of two Goldball 2 balloons (Balt
Extrusion, Montmorency, France), which
were deployed in the right ICA (Figure 1D)
petrous and cervical segments. The final
angiographic control showed a complete
occlusion of the right ICA (Figure 1E).
Three weeks after the initial procedure,
the patient’s condition showed progressive worsening of visual acuity, occular
proptosis, conjuctival hyperemia and occular movement restriction in the right
eye (Figure 2A). A new CAG was performed and it showed persistence in the
right ICA occlusion in its origin andA an
intracavernous pseudoaneurysm measuring approximately 30 mm, associated
with ipsilateral carotid-cavernous fistula
(CCF), which became opacified after
contrast injection in left ICA, through
the ACoA (Figure 3A). The patient was
then submitted to a new endovascular
procedure in which a left ICA selective
catheterism was performed, with lesion
microcatheterism through the ACoA
(Figura 3B) and embolization with coils
(Figure 3C). The final angiographic control showed absence of pseudoaneurysm and CCF opacification (Figure 3D).
The procedure was performed without
complications and the patient’s condition progressed to the regression of
symptoms (Figure 2B), save a discrete
visual deficit to the right.
Revista Chilena de Neurocirugía 38 : 2012
Figure 2: A – Patient’s ocular appearance previous to the second procedure, showing mydriasis, occular
hyperemia and proptosis in the right eye. B – final aspect, following treatment, showing regression of occular
signs.
Discussion
Diverse diagnostic and therapeutic procedures can determine an accidental
carotid artery injury, such as: anterior
cervical column surgery, central venous
catheter insertion, chiropractic cervical
manipulation, cerebral angiographies,
middle ear surgery, percutaneous procedure for trigeminal neuralgia treatment,
skull base surgeries, tracheostomy and
transsphenoidal surgery1.
Specifically in transsphenoidal surgeries, the incidence of carotid artery laceration is 0.3 to 0.4%1,6,7. These lesions
represent well-documented complications and can have catastrophic results
if not adequately treated. In the majority
of cases, it is caused by direct surgical
trauma to the intracavernous artery seg-
Figure 3: A – Left internal carotid artery angiography (frontal view), showing a pseudoaneurysm in the
intracavernous segment of the right ICA, associated with an ipsilateral carotidocavernous fistula (arrow),
which became opacified through the ACoA. B and C - Lesions microcatheterism and coiling performed
through the left internal carotid and anterior communicating arteries. D – final angiographic control of the
left internal carotid artery, in frontal view, showing complete occlusion of the fistula and pseudoaneurysm.
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Revista Chilena de Neurocirugía 38 : 2012
ment3. As a consequence, there may
be bleeding, vascular spasms, arterial
thrombosis, embolism and the formation of pseudoaneurysms and carotidcavernous fistulas2,3,4,5. In most cases
of iatrogenic CCF, the accidental injury
causes the formation of a pseudoaneurysm that ruptures immediately to the
cavernous sinus. In this case, by contrast, was initially formed a pseudoaneurysm that was treated with occlusion
of the vessel. Fistula formation occurred
later, and through the cross flow from
the other carotid artery. This makes this
case even more different. The predisposing factors for the ICA iatrogenic lesion
during transsphenoidal surgery most
cited in the literature are: large invasive
adenomas, reoperations, previous radiotherapy in the sellar region, previous
prolonged use of dopaminergic agonists
and radical surgeries for tumors which
invade the cavernous sinus3.
ICA anatomical variations, its proximity
to the medial line2 and adjacent structures can also be predisposing factors
for ICA lesions during transsphenoidal
surgery. Renn and Rhoton8 demonstrated that in 71% of the cases, the ICA
projects itself into the sphenoid sinus
and in 4% it is covered exclusively by the
cavernous sinus duramater and sphenoid sinus mucosa, favoring a lesion in
the same during transsphenoidal sur-
gery2. In this way, a detailed preoperatory anatomical assessment by imaging
(MRI and computed tomography - CT)
becomes imperative in order to minimize
the risk of iatrogenic arterial lesion, especially in patients with aforementioned
risk factors2,3. Other methods of evaluating the sellar region, such as the sellar
3D angiotomography, the paranasal region osseal window CT, the encephalic
angioresonance and Doppler ultrasound
(MicroDoppler Ultrasound), have already
been described in the literature as being
utilized in cases in which the MRI is not
sufficient to detail its anatomy3,4.
The ICA lesion must be rapidly diagnosed and treated. The initial measures
include local tamponade, direct repair of
the lesion or even surgical occlusion of
the lesioned artery1,2,5, until the patient
is stabilized, in order to procede with
the cerebral angiography. Traditionally,
the surgical or endovascular occlusion
has been used for the definitive treatment of these lesions. As the surgical
occlusion is associated with a larger incidence of complications, the endovascular treatment has been more amply
employed2,5,8. In the case that the CAG
shows an arterial lesion, endovascular
occlusion of the vessel should be considered once the occlusion test has been
performed2, as in the present case. In
cases in which the occlusion test shows
that the patient would not withstand the
lesioned artery occlusion, bypass surgery prior to its occlusion should be considered9. Curren-tly, the employment of
stents has been shown to be useful in
situations in which the occlusion is contraindicated2,10. In addition to preserving
the ICA flow, it allows for a rapid interruption of the bleeding and stabilization of
the patient2. There are some case series
describing the successful use of stents
with preservation of flow in treatment of
carotid-cavernous fistulas, however a
larger follow-up and further studies are
needed to establish definitive conclusions9,10.
In this way, ICA laceration during transsphenoidal surgery is a rare complication, but when it occurs it can be fatal.
The prevention is the best treatment for
any accidental lesion, the different imaging methods being fundamental for
this. Hopefully, accumulated knowledge
and experience will reduce this type of
complication in the future. Utilization of
endovascular techniques has allowed for
satisfactory treatment of this condition
and new studies are necessary for the
consolidation of endovascular methods
which maintain the arterial flow.
Recibido: 13.08.12
Aceptado: 11.09.12
References
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surgery. Surg Neurol 2009; 72 (6): 741-6.
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Pituitary 2010; 13 (2): 160-7.
4. Ahuja A, Guterman LR, Hopkins LN. Carotid cavernous fistula and false aneurysm of the cavernous carotid artery: complications of transsphenoidal
surgery. Neurosurgery 1992; 31 (4); 774-9.
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7. Laws ER Jr. Vascular complications of transsphenoidal surgery. Pituitary 1999; 2 (2): 163-70.
8. Renn WH, Rhoton AL Jr. Microsurgical anatomy of the sellar region. J Neurosurg 1975; 43 (3): 288-98.
9. Kobayashi N, Miyachi S, Negoro M, et al. Endovascular treatment strategy for direct carotid-cavernous fistulas resulting from rupture of
intracavernous carotid aneurysms. Am J Neuroradiol 2003; 24 (9): 1789-96.
10. Morón FE, Klucznik RP, Mawad ME, et al. Endovascular treatment of high-flow carotid cavernous fistulas by stent-assisted coil placement.
Am J Neuroradiol 2005; 26 (6): 1399-404.
Corresponding author:
Guilherme Brasileiro de Aguiar, MD.
Department of Surgery, Division of Neurosurgery, Santa Casa Medical School.
São Paulo, Brazil.
Rua Cesário Motta Jr., 112 - Vila Buarque.
01221-900. São Paulo - SP. Brazil.
Tel: 55 11 21767000
Email: [email protected]
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