Andrea Giorgianni1, Fabio Pozzi2, Carlo Pellegrino1, Stefania Padovan3, Apostolos Karligkiotis4, Paolo Castelnuovo4, Davide Locatelli5. 1. Division of Neuroradiology, Ospedale di Circolo e Fondazione Macchi, Varese, Italy. 2. Division of Neurosurgery, University of Insubria-Varese, Ospedale di Circolo e Fondazione Macchi, Varese, Italy; Head and Neck Surgery & Forensic Dissection Research Center, University of Insubria-Varese, Ospedale di Circolo e Fondazione Macchi, Varese, Italy. Electronic address: fabio.wells@asst-settelaghi.it. 3. Division of Otorhinolaryngology, University of Insubria-Varese, Ospedale di Circolo e Fondazione Macchi, Varese, Italy; Division of Neurosurgery, University of Pavia, Policlinico San Matteo Fondazione IRCCS, Pavia, Italy. 4. Division of Otorhinolaryngology, University of Insubria-Varese, Ospedale di Circolo e Fondazione Macchi, Varese, Italy; Head and Neck Surgery & Forensic Dissection Research Center, University of Insubria-Varese, Ospedale di Circolo e Fondazione Macchi, Varese, Italy. 5. Division of Neurosurgery, University of Insubria-Varese, Ospedale di Circolo e Fondazione Macchi, Varese, Italy; Head and Neck Surgery & Forensic Dissection Research Center, University of Insubria-Varese, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.
Abstract
BACKGROUND: Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries. CASE REPORT: We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction. CONCLUSIONS: Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.
BACKGROUND: Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries. CASE REPORT: We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction. CONCLUSIONS: Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.
Authors: Mohammed Bafaquh; Sami Khairy; Mahmoud Alyamany; Abdullah Alobaid; Gmaan Alzhrani; Ali Alkhaibary; Wafa F Aldhafeeri; Areej A Alaman; Hanan N Aljohani; Basim Noor Elahi; Fatimah A Alghabban; Yasser Orz; Abdulrahman Y Alturki Journal: Surg Neurol Int Date: 2020-10-21