Internal carotid artery injury in the endoscopic transsphenoidal surgery for pituitary adenoma: an uncommon case and literature review

Complications of the transsphenoidal surgery (TSS) for pituitary adenoma (PA) include vascular injury, nerve injury and nervous system infection. Among these, the consequences of internal carotid artery (ICA) injury are the most serious, and its mortality and disability rates are very high. The TSS was used in 889 patients with PA, among which there was 1 case of ICA injury. In this uncommon case of bromocirptine-resistant macro-prolatinoma, the patient had received an ultrahigh dose of oral bromocriptine for almost three years and was intraoperatively found to have a tenacious tumor texture and close adhesion of the tumor capsule to the ICA. Resection of the tumor capsule required excessive force, resulting in the rupture at the A1 origin of the left ICA. Endovascular balloon occlusion was used after urgent angiography. The patient died in two weeks even with intensive treatment. Although the underlying mechanism is still obscure, bromocriptine-inducing tumor fibrosis in PA is relatively common. For these patients with excessive dose of bromocriptine, tumor fibrosis and ICA injury should be seriously considered and performing a complete preoperative imaging evaluation to achieve accurate intraoperative positioning and carefully performing the operation are needed to preventing ICA injury. In some cases, resection of the tumor pseudocapsule should not be forced to avoid ICA injury.