Bilateral Intracavernous Carotid Artery Pseudoaneurysms as a Result of Sellar Reconstruction during the Transsphenoidal Resection of a Pituitary Macroadenoma: Case Report

Objective and Importance: Transsphenoidal surgery is considered to be a safe, relatively low risk procedure for the resection of pituitary lesions. Although rare, injury to the internal carotid artery is a potentially devastating complication associated with the transsphenoidal approach. The authors report a unique case in which the patient developed mirror pseudoaneurysms of the cavernous carotid arteries after an apparently uneventful transsphenoidal procedure, a complication attributed to the reconstruction of the sellar floor. Clinical Presentation: The patient is a 55-year-old gentleman who presented to the emergency room with severe epistaxis nearly 4 weeks after undergoing an uncomplicated transsphenoidal resection of a pituitary adenoma. An emergency cerebral angiogram was performed which demonstrated bilateral cavernous carotid artery pseudoaneurysms, a complication attributed to the placement of a synthetic implant in the sellar floor. While on the angiography table, the patient again developed massive epistaxis, with enlargement of the left-sided pseudoaneurysm from 3.4 x 2.5 x 2.1 mm to 4.5 x 3.7 x 3 mm. Intervention: The left cavernous carotid artery was occluded using 8 coils. The right-sided pseudoaneurysm was not treated at the time of the angiogram, and was managed conservatively. The patient subsequently developed an expressive aphasia, with an MRI revealing multiple areas of diffusion-weighted abnormalities. Within several days the patient's speech returned to normal, and he was discharged home eleven days after presenting to the emergency room. Follow-up imaging 6 weeks later showed complete obliteration of the left cavernous carotid artery with distal reconstitution, and a decrease in size of the right-sided pseudoaneurysm. Conclusion: While considered to be a relatively safe procedure, the transsphenoidal approach for resection of pituitary lesions is not without risks. Injury to the internal carotid artery is arguably the most catastrophic complication seen with pituitary surgery. Although it typically occurs during the dural opening, or during tumor removal, this case illustrates that the neurosurgeon must be conscious of this risk throughout every aspect of the case. For cases when sellar reconstruction is performed, specific attention should be paid to ensuring that an appropriately sized graft is used.