We describe a case of iatrogenic carotid injury with secondary carotid-cavernous fistula (CCF) treated with a silk flow diverter stent placed within the injured internal carotid artery and coils placed within the cavernous sinus. Flow diverters may offer a simple and potentially safe vessel-sparing option in this rare complication of transsphenoidal surgery. The management options are discussed and the relevant literature is reviewed.
BlackPMZervasNTCandiaGL. Incidence and management of complications of transsphenoidal operation for pituitary adenomas. Neurosurgery1987; 20: 920–924.
2.
RaymondJHardyJCzepkoR. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. Am J Neuroradiol1997; 18: 655–665.
3.
LawsERJrKernEB. Complications of trans-sphenoidal surgery. Clin Neurosurg1976; 23: 401–416.
4.
CiricIRaginABaumgartnerC. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery1997; 40: 225–236. Discussion 236–227.
CabezudoJMCarrilloRVaqueroJ. Intracavernous aneurysm of the carotid artery following transsphenoidal surgery. Case report. J Neurosurg1981; 54: 118–121.
8.
PaullusWSNorwoodCWMorganHW. False aneurysm of the cavernous carotid artery and progressive external ophthalmoplegia after transsphenoidal hypophysectomy. Case report. J Neurosurg1979; 51: 707–709.
9.
ReddyKLesiukHWestM. False aneurysm of the cavernous carotid artery: a complication of transsphenoidal surgery. Surg Neurol1990; 33: 142–145.
10.
Ruiz-JuretschkeFCastroEMateo SierraO. Massive epistaxis resulting from an intracavernous internal carotid artery traumatic pseudoaneurysm: complete resolution with overlapping uncovered stents. Acta neurochir (Wien)2009; 151: 1681–1684.
11.
KachharaRMenonGBhattacharyaRN. False aneurysm of cavernous carotid artery and carotid cavernous fistula: complications following transsphenoidal surgery. Neurol India2003; 51: 81–83.
12.
ChengKYLeeKWChiangFY. Rupture of radiation-induced internal carotid artery pseudoaneurysm in a patient with nasopharyngeal carcinoma – spontaneous occlusion of carotid artery due to long-term embolizing performance. Head Neck2008; 30: 1132–1135.
13.
CrowleyRWDumontASJaneJAJr. Bilateral intracavernous carotid artery pseudoaneurysms as a result of sellar reconstruction during the transsphenoidal resection of a pituitary macroadenoma: case report. Min Invas Neurosurg2009; 52: 44–48.
14.
LinskeyMEJungreisCAYonasH. Stroke risk after abrupt internal carotid artery sacrifice: accuracy of preoperative assessment with balloon test occlusion and stable xenon-enhanced CT. Am J Neuroradiol1994; 15: 829–843.
15.
GillerCASteigPBatjerHH. Transcranial doppler ultrasound as a guide to graded therapeutic occlusion of the carotid artery. Neurosurgery1990; 26: 307–311.
16.
KadyrovNAFriedmanJANicholsDA. Endovascular treatment of an internal carotid artery pseudoaneurysm following transsphenoidal surgery. Case report. J Neurosurg2002; 96: 624–627.
17.
ParkYSJungJYAhnJY. Emergency endovascular stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery. Surg Neurol2009; 72: 741–746.
18.
AhujaAGutermanLRHopkinsLN. Carotid cavernous fistula and false aneurysm of the cavernous carotid artery: complications of transsphenoidal surgery. Neurosurgery1992; 31: 774–778. discussion 778–779.
19.
SaatciICekirgeHSOzturkMH. Treatment of internal carotid artery aneurysms with a covered stent: experience in 24 patients with mid-term follow-up results. Am J Neuroradiol2004; 25: 1742–1749.
HigashidaRTHalbachVVTsaiFY. Interventional neurovascular treatment of traumatic carotid and vertebral artery lesions: results in 234 cases. Am J Roentgenol1989; 153: 577–582.
22.
KobayashiNMiyachiSNegoroM. Endovascular treatment strategy for direct carotid-cavernous fistulas resulting from rupture of intracavernous carotid aneurysms. Am J Neuroradiol2003; 24: 1789–1796.
23.
GuptaAKPurkayasthaSKrishnamoorthyT. Endovascular treatment of direct carotid cavernous fistulae: a pictorial review. Neuroradiology2006; 48: 831–839.
24.
HattoriIIwasakiKHorikawaF. [Treatment of a ruptured giant internal carotid artery pseudoaneurysm following transsphenoidal surgery: case report and literature review]. No Shinkei Geka2006; 34: 1141–1146. (in Japanese).
25.
StruffertTBuhkJHBuchfelderM. Coil migration after endovascular coil occlusion of internal carotid artery pseudoaneurysms within the sphenoid sinus. Min Invas Neurosurg2009; 52: 89–92.
26.
LiMHLiYDGaoBL. A new covered stent designed for intracranial vasculature: application in the management of pseudoaneurysms of the cranial internal carotid artery. Am J Neuroradiol2007; 28: 1579–1585.
27.
TahtinenOIManninenHIVanninenRL. The silk flow-diverting stent in the endovascular treatment of complex intracranial aneurysms: technical aspects and midterm results in 24 consecutive patients. Neurosurgery2012; 70: 617–623. Discussion 623–624.
28.
SaatciIYavuzKOzerC. Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. Am J Neuroradiol2012; 33: 1436–1446.
29.
BrigantiFNapoliMTortoraF. Italian multicenter experience with flow-diverter devices for intracranial unruptured aneurysm treatment with periprocedural complications – a retrospective data analysis. Neuroradiology2012; 54: 1145–1152.
30.
BergeJBiondiAMachiP. Flow-diverter silk stent for the treatment of intracranial aneurysms: 1-year follow-up in a multicenter study. Am J Neuroradiol2012; 33: 1150–1155.
31.
NadarajahMPowerMBarryB. Treatment of a traumatic carotid-cavernous fistula by the sole use of a flow diverting stent. J Neurointerv Surg2012; 4: e1.
32.
HoogenboomTCvan BeurdenRMvan TeylingenB. Optimization of the reconstruction interval in neurovascular 4D-CTA imaging. A technical note. Interv Neuroradiol2012; 18: 377–379.
33.
WillemsPWTaeshineetanakulPSchenkB. The use of 4D-CTA in the diagnostic work-up of brain arteriovenous malformations. Neuroradiology2012; 54: 123–131.
