the transsphenoidal approach is the most commonly utilized operation for the surgical treatment of sellar lesions and is a relatively safe operation 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 described once before.2 common complications of transsphenoidal operations include endocrine abnormalities and cerebrospinal fluid ( csf ) leaks.3 vascular injury is a rare but serious complication of transsphenoidal surgery encountered in 0.8 to 1.1% of cases , with an associated mortality of nearly 30%.456 the majority of vascular injuries are identified at the time of surgery , usually resulting from direct injury to the internal carotid artery during resection of tumor within the cavernous sinus or upon opening of the dura , often resulting in profuse arterial hemorrhage.6789 other described vascular complications include vasospasm , carotid thrombosis , cavernous sinus thrombosis , embolism , caroticocavernous fistula , or pseudoaneurysm.237810111213141516171819 postoperative carotid pseudoaneurysm , though rare , represents a grave risk to the patient if unrecognized .
it may lead to delayed hemorrhagic or embolic complications when the patient is no longer in a monitored hospital setting .
we present a rare case of delayed pseudoaneurysm and embolic stroke following erosion of a rigid plate into the cavernous internal carotid artery .
a 57-year - old man with a nonfunctional pituitary macroadenoma causing vision loss underwent a gross total , endoscopic transsphenoidal resection ( fig .
1 ) . the tumor was invading the right cavernous sinus wall . during the procedure to resect the tumor from this region
, there was some venous bleeding that was easily controlled by temporarily packing the area using gelfoam ( pfizer , new york , new york , usa ) with thrombin .
following resection , a custom - fit bioabsorbable plate was placed extradurally to reconstruct the sellar floor .
four weeks later , he experienced epistaxis for which he was treated at an outside emergency department .
six weeks following the operation , he presented to clinic with dysarthria as well as left hand and facial weakness and was admitted for further work - up .
neuroimaging revealed subacute infarcts in right middle cerebral artery distribution . computed tomography ( ct ) angiogram showed a 6  4 mm pseudoaneurysm located on the medial wall of the right cavernous internal carotid artery .
a hypodensity likely representing the implanted absorbable plate was noted to be compressing the right carotid artery in this region ( fig .
stent coiling with placement of eight detachable coils was used to successfully obliterate the pseudoaneurysm ( fig .
3 ) . follow - up digital subtraction angiogram and ct angiogram demonstrated durable obliteration of the pseudoaneurysm with preserved flow through the carotid artery . on follow - up , the patient 's neurological deficits have resolved .  
ct - angiogram of the brain showing hypodense absorbable plate compressing the right cavernous carotid artery .  
digital subtraction angiogram showing right cavernous carotid pseudoaneurysm before and after stent - assisted coil embolization .
iatrogenic carotid pseudoaneurysm is an extremely rare complication of transsphenoidal surgery , with only 24 reported cases found in our review of the literature .
only one previous case was associated with sellar floor reconstruction.2 a pseudoaneurysm is caused by injury to the carotid artery wall leading to an encapsulated hematoma in communication with the ruptured artery . in general , an aneurysmal rupture of the cavernous carotid will result in a caroticocavernous fistula .
however , severe epistaxis and pituitary apoplexy have been reported in patients whose medial cavernous sinus wall has been eroded by tumor or violated during surgery.4 thus , the consequences of aneurysmal rupture support urgent treatment of even incidentally diagnosed lesions , as they represent a grave risk to the postoperative patient .
because of the extremely low reported incidence of pseudoaneurysms after transsphenoidal surgery , postoperative angiography is not routinely performed.6 although in cases where there is significant arterial bleeding or concern for carotid injury , many experts recommend immediate postoperative angiography.615 based on the uneventful operative course and features observed on ct angiogram , the pseudoaneurysm was likely caused by erosion of the absorbable plate into the cavernous carotid artery .
this has been previously reported by crowley et al and was also associated with delayed severe epistaxis followed by transient ischemic deficits.2 despite its low complication rates , these cases highlight the risks associated with sellar floor reconstruction.20 both patients were treated via endovascular means with good results . in a majority of cases , the absorbable plates used to reconstruct the bony sellar floor can be custom fit to approximate the size of the defect .
the surgeon must take extra care to ensure that the cut edges are as round and smooth as possible , and that the size of the plate is just large enough to be inserted beneath the bony edges of the lateral sellar floor , and in an extradural fashion .
perhaps more importantly , the authors now make every attempt to only use a rigid buttress when necessary  that is , only in cases where intraoperative csf leaks are observed in the setting of a large bony defect that can not be repaired or adequately buttressed with routine techniques , including cellulose sponge , duragen ( integra lifesciences corporation , plainsboro , new jersey , usa ) , and fibrin glue . according to our search of the literature ,
18 publications reporting 24 cases of iatrogenic carotid pseudoaneurysm following transsphenoidal surgery were identified ( table 1 ) . among published cases ,
the mean patient age was 45.6 ( range 22 to 74 ) , with a slight female predominance ( 13/22 patients ) .
intraoperative arterial hemorrhage requiring packing was described in 17 of 24 cases ; 21% of cases reported the operation as uneventful .
we recommend additional delayed imaging in patients with high suspicion for arterial injury , considering multiple reports in which the immediate postoperative angiogram was negative , only to have the patient present with a pseudoaneurysm in a delayed fashion.161721 common presentations prior to diagnosis included severe epistaxis,10 postoperative high - suspicion angiogram,10 routine follow - up imaging,2 and cranial neuropathy.1 the interval to diagnosis following surgery varied between 0 days and 10 years .
delay to diagnosis may lead to aneurysmal rupture or embolic stroke outside of a monitored setting .
in fact , in nine cases reported in the literature , the patient was discharged from the hospital prior to the diagnosis being made .
abbreviations : acth , adrenocorticotropic hormone ; bto , balloon test occlusion ; csf , cerebrospinal fluid ; ct , computed tomography ; gh , growth hormone ; ica , internal carotid artery ; mri , magnetic resonance imaging ; nr , not reported , pod , postoperative day ; ptca , percutaneous trasnluminal coronary angioplasty ; ptfe , polytetrafluoroethylene .
although conservative management may be an option , one report in which a patient refused surgical management resulted in death at 2 years secondary to uncontrollable epistaxis.15 despite reports that conservatively managed postprocedure femoral pseudoaneurysms spontaneously close in 89% of patients , we recommend treatment even in incidental false aneurysms of the carotid because of the higher morbidity associated with carotid rupture.22 additional surgical options for cavernous carotid pseudoaneurysms include extracranial to intracranial ( ec - ic ) bypass with carotid occlusion , craniotomy with direct repair of the carotid artery within the cavernous sinus , or trapping the aneurysm via cervical carotid ligation and supraclinoid carotid clip ligation.613152324 endovascular options may include balloon occlusion of the carotid artery , coil embolization of the pseudoaneurysm or carotid artery , and/or placement of a flow - diverting stent.378121518 with the advancement in endovascular techniques , open surgery has become less common .
successful carotid artery occlusion , aneurysm trapping , stenting , or coiling can be achieved without subjecting the patient to the risks associated with open craniotomy and manipulation of a cavernous carotid pseudoaneurysm .
some authors prefer carotid occlusion , when feasible , to avoid the risks associated with manipulation of the false aneurysm .
struffert described two cases requiring repeat transsphenoidal surgery to retrieve coils that had migrated from a pseudoaneurysm into the patients ' nostril.17 the use of a flow - iverting stent may obviate the need for an intra - aneurysmal embolization.1825 however , flow - diverting stents surrender future endovascular access to the pseudoaneurysm , because once deployed a microcatheter can not be passed through it . if the patient experiences breakthrough bleeding , he or she could not be treated with further embolic agents
although rare , erosion of an absorbable plate used to reconstruct the bony sellar floor may cause a carotid artery pseudoaneurysm , potentially resulting in a subacute presentation of epistaxis or embolic stroke .
the authors ' preference is to avoid the use of rigid plating for sellar floor reconstruction in the absence of intraoperative csf leaks , unless required to buttress a large skull base defect and csf leak repair construct .
short - segment embolization with stent coiling is the preferred option for the treatment of iatrogenic carotid pseudoaneurysms following endonasal skull base operations .
 background bioabsorbable plates are frequently utilized in the repair of skull base defects following transsphenoidal operations . 
 traumatic intracranial pseudoaneurysms are a rare complication of transsphenoidal surgery . to date , iatrogenic carotid pseudoaneurysm associated with the use of an absorbable 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 reconstruct the sellar floor . 
 he experienced delayed repeated epistaxis , followed by a right middle cerebral artery distribution embolic stroke . 
 computed tomorgraphy ( 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 obliterate the pseudoaneurysm , and the patient fully recovered.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 , unless it is required to buttress a large skull base defect . 
 short - segment embolization with stent coiling is the preferred treatment option for carotid pseudoaneurysms following transsphenoidal operations . 
Introduction
Case Report
Discussion
Conclusion