Clin Neuroradiol DOI 10.1007/s00062-014-0340-4
Correspondence
Iatrogenic Pseudoaneurysm of the Meningohypophyseal Trunk; A Rare Complication of Trans-sphenoidal Surgery C. K. Hong · K. S. Lee · B. M. Kim · E.-W. Jang · S. H. Suh
Received: 24 March 2014 / Accepted: 13 August 2014 © Springer-Verlag Berlin Heidelberg 2014
Introduction Microscopic trans-sphenoidal surgery is a well-established procedure for the removal of pituitary adenoma since the 1960s, which is associated with good outcomes. Although arterial injury during or after trans-sphenoidal surgery was a rare complication for pituitary adenoma (1 %), it was related to significant morbidity (24 %) and mortality (14 %) [1]. A pseudoaneurysm of the meningohypophyseal trunk (MHT) is an uncommon pathology following trans-sphenoidal surgery, which may come to a catastrophic consequence with massive epistaxis, or intracranial hemorrhage and immediate treatment is required to avoid these disasters. While endovascular treatment (EVT) has been recently proposed as an alternative, there is no case report about EVT of the MHT pseudoaneurysm.
S. H. Suh, MD () Severance Institute of Vascular and Metabolic Research, Yonsei University College of Medicine, 712 Eonjoo-ro, Gangnam-gu, 135-720 Seoul, Korea e-mail: [email protected] C. K. Hong, MD · K. S. Lee, MD · E.-W. Jang, MD Department of Neurosurgery, Seoul, Korea B. M. Kim, MD Department of Radiology, Yonsei University College of Medicine, Seoul, Korea S. H. Suh, MD Department of Radiology, Gangnam Severance Hospital, Yonsei University, Seoul, Korea
We report our experience of EVT in a patient with iatrogenic injury of the MHT following the trans-sphenoidal surgery and review anatomical consideration and therapeutic management. Case Reports This 33-year-old man was diagnosed with pituitary macroadenoma and underwent microscopic trans-sphenoidal resection in the department of neurosurgery. His laboratory finding showed an increased level of prolactin and he had no neurologic deficit. Magnetic resonance imaging (MRI) showed a pituitary macroadenoma with invasion of the right cavernous sinus. Previously, he was not administered with bromocriptine. During exposure of the sella via a trans-sphenoidal access, it was found that the residual tumor was attached to the right cavernous sinus. In an attempt of tumor resection, it was complicated due to unexpected intraoperative arterial bleeding, which was temporarily arrested by nasal packing using gelfoam and hemostatic matrix (FloSeal; Baxter Inc., Deerfield, IL). The patient remained intact without neurologic deficit. Immediately after operation, brain MRI showed formation of a pseudoaneurysm near the resection margin, and cerebral angiography revealed a 2.5 mm-sized pseudoaneurysm from the right MHT (Fig. 1a and b). EVT was decided due to the patient’s condition and surgical risk, and an informed consent was obtained. Via the right femoral artery access, a 6 Fr guiding catheter (Envoy, Codman Neurovascular, Raynham, MA) was introduced into the right ICA. A 2.0 Fr microcatheter (preshaped J Excelsior, Stryker, Fremont, CA) was navigated into the proximal MHT under guidance of a 0.014-inch microwire (Synchro-2, Stryker) and advanced into the saccular lumen
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C. K. Hong et al.
Fig. 1 A 33-year-old man with the meningohypophyseal trunk pseudoaneurysm after trans-sphenoidal surgery. a Contrast-enhanced axial T1-weighted image demonstrated a pseudoaneurysm near the resection margin of the pituitary adenoma (arrowhead). b The right internal carotid artery (ICA) angiography showed a saccular pseudoaneurysm on the midportion of the meningohypophyseal trunk. c To fix the microcatheter and prevent from the risk of rebleeding or rupture, temporary ballooning was performed in the right ICA near the inlet of the right meningohypophyseal trunk during coiling. d Control angiography showed embolization of pseudoaneurysm as well as the meningohypophyseal trunk
carefully via the MHT. To prevent from protruding a microcatheter and possibility of rupture, temporary ballooning was performed with a Hyperglide occlusion balloon catheter (4 mm; eV3, Irvine, CA) in the right ICA, near the inlet of the right MHT (Fig. 1c). Coil embolization was performed using detachable coils and control angiography confirmed complete occlusion of the pseudoaneurysm as well as the right MHT (Fig. 1d). His postoperative course was uneventful without neurologic deficits and intracranial hemorrhage until discharge. He remained no symptoms at 12-month follow-up.
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Discussion The MHT is the largest branching vessel from the cavernous ICA, measuring 0.8 mm in an average diameter. It originates laterally from the posterior bend of the ICA and has commonly trifurcation into the tentorial, inferior hypophyseal, and dorsal meningeal arteries. The mean diameter of the tentorial artery is 0.7 mm, and the mean length is 15.4 mm, 10 % of which arise directly from the intracavernous ICA [2]. Cadaveric microsurgical study revealed that the MHT supplied the trochlear nerve, the abducens nerve, and medial Gasserian ganglion together with the inferolat-
Iatrogenic Pseudoaneurysm of the Meningohypophyseal Trunk; A Rare Complication of Trans-sphenoidal Surgery
eral trunk [3]. On cerebral angiography, the MHT showed wavy appearance in normal as well as in other pathologic conditions. While vascular complications of trans-sphenoidal surgery can be prevented with experience and a thorough knowledge of anatomy, arterial injuries still arise from surgically difficult lesions or other anatomical variant. Renn and Rhoton [4] described that the distance between the cavernous portion of both ICA was 12 mm in average. In 10 % of cases, both cavernous ICAs were located within 4 mm of the midline. When they bulged into the sphenoid sinus in 71 % of the specimen, 4 % had exposed into the sinus without bony protection. Moreover, other vascular anomalies, such as intrasellar trigeminal artery was also reported [5]. Raymond et al. [1] reported 21 arterial injuries among more than 1800 patients with trans-sphenoidal surgery and analyzed predisposing factors of theses complications, including cavernous sinus invasion by tumor, adhesion of the tumor to the ICA, previous surgical/radiation therapy, and long-term bromocriptine therapy. Therefore, a thorough evaluation with preoperative imaging is essential before trans-sphenoid surgery. This iatrogenic pseudoaneurysm was treated traditionally by the surgical technique. In case of intraoperative ICA injury, most of the cases were managed with nasal packing, carotid ligation, and surgical trapping [1]. However, pseudoaneurysms were detected several weeks or months after trans-sphenoidal surgery and postoperative angiography should be performed in suspicion of ICA injuries and EVT was also applied as an alternative to manage these lesions, including parent artery occlusion with latex balloon or coils, selective stent-assisted coiling, polyvinyl alcohol particle or tissue adhesive, and covered stent implantation. Cinar et al. [6] showed EVT with parent artery occlusion was a feasible option with acceptable morbidity and mortality. In this study, it was fortunate to be able to catheterize the MHT directly via the ipsilateral ICA, and pseudoaneurysm was treated by coils and balloon. It was possible that its anatomy and configuration might be changed after tumor resection. In addition, temporary ballooning could help to stabilize the microcatheter to the MHT and prevent from protruding. In fact, transarterial catheterization of the MHT is difficult owing to their small caliber, distal tortuosity, and sharp angulation to the ICA. To overcome this difficulty, Borden and Liebman [7] proposed usefulness of the contralateral access to the MHT, and Zhao et al. [8] described the
3
balloon-assisted microcatherization of the MHT. In embolization of pseudoaneurysm, we chose detachable coils, as no other embolic materials in that endosaccular coiling was feasible in this case, and use of detachable coil might be helpful to prevent from occlusion of distal vessel to the cranial nerves. Conclusion A pseudoaneurysm involving the MHT is an uncommon complication in trans-sphenoidal surgery, and we present the first case of the MHT pseudoaneurysm embolized with coil and balloon. Above all, it is important for the operators to deliberate this possibility associated with trans-sphenoidal surgery. In confronting this complication, an optimal therapeutic option should be determined with cerebral angiography. Conflict of Interest The authors declare that there are no actual or potential conflicts of interest in relation to this article.
References 1. Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol. 1997;18(4):655–65. 2. Banerjee AD, Ezer H, Nanda A. The artery of Bernasconi and Cassinari: a morphometric study for superselective catheterization. AJNR Am J Neuroradiol. 2011;32(9):1751–5. doi:10.3174/ajnr. A2552. 3. Krisht A, Barnett DW, Barrow DL, Bonner G. The blood supply of the intracavernous cranial nerves: an anatomic study. Neurosurgery. 1994;34(2):275–9; discussion 9. 4. Renn WH, Rhoton AL Jr. Microsurgical anatomy of the sellar region. J Neurosurg. 1975;43(3):288–98. doi:10.3171/ jns.1975.43.3.0288. 5. Lee KS, Kelly DL Jr. Intrasellar persistent trigeminal artery associated with a pituitary adenoma. Case report. J Neurosurg. 1989;70(2):271–3. doi:10.3171/jns.1989.70.2.0271. 6. Cinar C, Bozkaya H, Parildar M, Oran I. Endovascular management of vascular injury during transsphenoidal surgery. Interv Neuroradiol. 2013;19(1):102–9. 7. Borden NM, Liebman KM. Endovascular access to the meningohypophyseal trunk. AJNR Am J Neuroradiol. 2001;22(4):725–7. 8. Zhao WY, Krings T, Yang PF, Liu JM, Xu Y, Li Q, et al. Balloonassisted superselective microcatheterization for transarterial treatment of cranial dural arteriovenous fistulas: technique and results. Neurosurgery. 2012;71(2 Suppl. Operative):269–73; discussion ons73. doi:10.1227/NEU.0b013e3182684b70.
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Correspondence
Iatrogenic Pseudoaneurysm of the Meningohypophyseal Trunk; A Rare Complication of Trans-sphenoidal Surgery C. K. Hong · K. S. Lee · B. M. Kim · E.-W. Jang · S. H. Suh
Received: 24 March 2014 / Accepted: 13 August 2014 © Springer-Verlag Berlin Heidelberg 2014
Introduction Microscopic trans-sphenoidal surgery is a well-established procedure for the removal of pituitary adenoma since the 1960s, which is associated with good outcomes. Although arterial injury during or after trans-sphenoidal surgery was a rare complication for pituitary adenoma (1 %), it was related to significant morbidity (24 %) and mortality (14 %) [1]. A pseudoaneurysm of the meningohypophyseal trunk (MHT) is an uncommon pathology following trans-sphenoidal surgery, which may come to a catastrophic consequence with massive epistaxis, or intracranial hemorrhage and immediate treatment is required to avoid these disasters. While endovascular treatment (EVT) has been recently proposed as an alternative, there is no case report about EVT of the MHT pseudoaneurysm.
S. H. Suh, MD () Severance Institute of Vascular and Metabolic Research, Yonsei University College of Medicine, 712 Eonjoo-ro, Gangnam-gu, 135-720 Seoul, Korea e-mail: [email protected] C. K. Hong, MD · K. S. Lee, MD · E.-W. Jang, MD Department of Neurosurgery, Seoul, Korea B. M. Kim, MD Department of Radiology, Yonsei University College of Medicine, Seoul, Korea S. H. Suh, MD Department of Radiology, Gangnam Severance Hospital, Yonsei University, Seoul, Korea
We report our experience of EVT in a patient with iatrogenic injury of the MHT following the trans-sphenoidal surgery and review anatomical consideration and therapeutic management. Case Reports This 33-year-old man was diagnosed with pituitary macroadenoma and underwent microscopic trans-sphenoidal resection in the department of neurosurgery. His laboratory finding showed an increased level of prolactin and he had no neurologic deficit. Magnetic resonance imaging (MRI) showed a pituitary macroadenoma with invasion of the right cavernous sinus. Previously, he was not administered with bromocriptine. During exposure of the sella via a trans-sphenoidal access, it was found that the residual tumor was attached to the right cavernous sinus. In an attempt of tumor resection, it was complicated due to unexpected intraoperative arterial bleeding, which was temporarily arrested by nasal packing using gelfoam and hemostatic matrix (FloSeal; Baxter Inc., Deerfield, IL). The patient remained intact without neurologic deficit. Immediately after operation, brain MRI showed formation of a pseudoaneurysm near the resection margin, and cerebral angiography revealed a 2.5 mm-sized pseudoaneurysm from the right MHT (Fig. 1a and b). EVT was decided due to the patient’s condition and surgical risk, and an informed consent was obtained. Via the right femoral artery access, a 6 Fr guiding catheter (Envoy, Codman Neurovascular, Raynham, MA) was introduced into the right ICA. A 2.0 Fr microcatheter (preshaped J Excelsior, Stryker, Fremont, CA) was navigated into the proximal MHT under guidance of a 0.014-inch microwire (Synchro-2, Stryker) and advanced into the saccular lumen
13
2
C. K. Hong et al.
Fig. 1 A 33-year-old man with the meningohypophyseal trunk pseudoaneurysm after trans-sphenoidal surgery. a Contrast-enhanced axial T1-weighted image demonstrated a pseudoaneurysm near the resection margin of the pituitary adenoma (arrowhead). b The right internal carotid artery (ICA) angiography showed a saccular pseudoaneurysm on the midportion of the meningohypophyseal trunk. c To fix the microcatheter and prevent from the risk of rebleeding or rupture, temporary ballooning was performed in the right ICA near the inlet of the right meningohypophyseal trunk during coiling. d Control angiography showed embolization of pseudoaneurysm as well as the meningohypophyseal trunk
carefully via the MHT. To prevent from protruding a microcatheter and possibility of rupture, temporary ballooning was performed with a Hyperglide occlusion balloon catheter (4 mm; eV3, Irvine, CA) in the right ICA, near the inlet of the right MHT (Fig. 1c). Coil embolization was performed using detachable coils and control angiography confirmed complete occlusion of the pseudoaneurysm as well as the right MHT (Fig. 1d). His postoperative course was uneventful without neurologic deficits and intracranial hemorrhage until discharge. He remained no symptoms at 12-month follow-up.
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Discussion The MHT is the largest branching vessel from the cavernous ICA, measuring 0.8 mm in an average diameter. It originates laterally from the posterior bend of the ICA and has commonly trifurcation into the tentorial, inferior hypophyseal, and dorsal meningeal arteries. The mean diameter of the tentorial artery is 0.7 mm, and the mean length is 15.4 mm, 10 % of which arise directly from the intracavernous ICA [2]. Cadaveric microsurgical study revealed that the MHT supplied the trochlear nerve, the abducens nerve, and medial Gasserian ganglion together with the inferolat-
Iatrogenic Pseudoaneurysm of the Meningohypophyseal Trunk; A Rare Complication of Trans-sphenoidal Surgery
eral trunk [3]. On cerebral angiography, the MHT showed wavy appearance in normal as well as in other pathologic conditions. While vascular complications of trans-sphenoidal surgery can be prevented with experience and a thorough knowledge of anatomy, arterial injuries still arise from surgically difficult lesions or other anatomical variant. Renn and Rhoton [4] described that the distance between the cavernous portion of both ICA was 12 mm in average. In 10 % of cases, both cavernous ICAs were located within 4 mm of the midline. When they bulged into the sphenoid sinus in 71 % of the specimen, 4 % had exposed into the sinus without bony protection. Moreover, other vascular anomalies, such as intrasellar trigeminal artery was also reported [5]. Raymond et al. [1] reported 21 arterial injuries among more than 1800 patients with trans-sphenoidal surgery and analyzed predisposing factors of theses complications, including cavernous sinus invasion by tumor, adhesion of the tumor to the ICA, previous surgical/radiation therapy, and long-term bromocriptine therapy. Therefore, a thorough evaluation with preoperative imaging is essential before trans-sphenoid surgery. This iatrogenic pseudoaneurysm was treated traditionally by the surgical technique. In case of intraoperative ICA injury, most of the cases were managed with nasal packing, carotid ligation, and surgical trapping [1]. However, pseudoaneurysms were detected several weeks or months after trans-sphenoidal surgery and postoperative angiography should be performed in suspicion of ICA injuries and EVT was also applied as an alternative to manage these lesions, including parent artery occlusion with latex balloon or coils, selective stent-assisted coiling, polyvinyl alcohol particle or tissue adhesive, and covered stent implantation. Cinar et al. [6] showed EVT with parent artery occlusion was a feasible option with acceptable morbidity and mortality. In this study, it was fortunate to be able to catheterize the MHT directly via the ipsilateral ICA, and pseudoaneurysm was treated by coils and balloon. It was possible that its anatomy and configuration might be changed after tumor resection. In addition, temporary ballooning could help to stabilize the microcatheter to the MHT and prevent from protruding. In fact, transarterial catheterization of the MHT is difficult owing to their small caliber, distal tortuosity, and sharp angulation to the ICA. To overcome this difficulty, Borden and Liebman [7] proposed usefulness of the contralateral access to the MHT, and Zhao et al. [8] described the
3
balloon-assisted microcatherization of the MHT. In embolization of pseudoaneurysm, we chose detachable coils, as no other embolic materials in that endosaccular coiling was feasible in this case, and use of detachable coil might be helpful to prevent from occlusion of distal vessel to the cranial nerves. Conclusion A pseudoaneurysm involving the MHT is an uncommon complication in trans-sphenoidal surgery, and we present the first case of the MHT pseudoaneurysm embolized with coil and balloon. Above all, it is important for the operators to deliberate this possibility associated with trans-sphenoidal surgery. In confronting this complication, an optimal therapeutic option should be determined with cerebral angiography. Conflict of Interest The authors declare that there are no actual or potential conflicts of interest in relation to this article.
References 1. Raymond J, Hardy J, Czepko R, Roy D. Arterial injuries in transsphenoidal surgery for pituitary adenoma; the role of angiography and endovascular treatment. AJNR Am J Neuroradiol. 1997;18(4):655–65. 2. Banerjee AD, Ezer H, Nanda A. The artery of Bernasconi and Cassinari: a morphometric study for superselective catheterization. AJNR Am J Neuroradiol. 2011;32(9):1751–5. doi:10.3174/ajnr. A2552. 3. Krisht A, Barnett DW, Barrow DL, Bonner G. The blood supply of the intracavernous cranial nerves: an anatomic study. Neurosurgery. 1994;34(2):275–9; discussion 9. 4. Renn WH, Rhoton AL Jr. Microsurgical anatomy of the sellar region. J Neurosurg. 1975;43(3):288–98. doi:10.3171/ jns.1975.43.3.0288. 5. Lee KS, Kelly DL Jr. Intrasellar persistent trigeminal artery associated with a pituitary adenoma. Case report. J Neurosurg. 1989;70(2):271–3. doi:10.3171/jns.1989.70.2.0271. 6. Cinar C, Bozkaya H, Parildar M, Oran I. Endovascular management of vascular injury during transsphenoidal surgery. Interv Neuroradiol. 2013;19(1):102–9. 7. Borden NM, Liebman KM. Endovascular access to the meningohypophyseal trunk. AJNR Am J Neuroradiol. 2001;22(4):725–7. 8. Zhao WY, Krings T, Yang PF, Liu JM, Xu Y, Li Q, et al. Balloonassisted superselective microcatheterization for transarterial treatment of cranial dural arteriovenous fistulas: technique and results. Neurosurgery. 2012;71(2 Suppl. Operative):269–73; discussion ons73. doi:10.1227/NEU.0b013e3182684b70.
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