Emergency placement of a Flow Diverter Stent for an Iatrogenic Internal Carotid Artery Injury During Endoscopic Pituitary Surgery

Abstract

Internal carotid artery (ICA) injury is 1 of the most feared complications in endoscopic pituitary surgery. Different endovascular techniques are available for the management of early and delayed ICA injuries. We report a case of emergency endovascular treatment with a flow diverter stent for an ICA injury that occurred during endoscopic transphenoidal surgery for pituitary macroadenoma in a 66-year-old man. Effective intraoperative hemostasis was achieved by direct packing of the sphenoid sinus. Digital subtraction angiography demonstrated extravasation of the contrast agent into the sphenoidal sinus from the anterior genu of the intracavernous portion of the right ICA. Balloon test occlusion resulted in a prominent delay in the venous phase in the right hemisphere during occlusion of the right ICA. Taking into account the hemodynamic stability and the absence of intracranial bleeding, we considered the ICA injury as if it were a pseudoaneurysm. Therefore, an emergency release of a flow diverter stent was performed, in association with antiplatelet therapy. No periprocedural complications occurred. The patient was discharged without neurologic deficits. The last follow-up studies at 6 months (digital subtraction angiography and magnetic resonance imaging) confirmed the regular placement of the stent and vessel reconstruction. Despite the presence of acute hemorrhage and the need for antiplatelet therapy, a flow diverter stent can be used as emergency treatment of ICA injury in selected circumstances.