- Email: [email protected]
Pseudoaneurysm of anterior communicating artery following transsphenoidal surgery for craniopharyngioma
Endoscopic treatment of SEHs/Pseudoaneurysm
21. GundryLR, HeithoffKB. Epiduralhematomaof the lumbarspine: 18 surgicallyconfirmedcases. Radiology 1993; 187:427~43i. 22. LobitzB, GrateI. Acute epiduralhematomaof the cervicalspine: an unusual cause of neck pain. SouthMed J 1995; 88(5): 580-582. 23. MannaJW, Bail MR, Lee KS, McWhorterJM. Spontaneousspinal epidural hematomacomplicatingPaget's disease of the spine. Spine 1995; 14(8): 900-902. 24. CooperDW. Spontaneousspinal epiduralhematoma. J Neurosurg 1967; 26: 343 346. 25. BeattyRM, WinstonKR. Spontaneouscervicalepiduralhematoma.A considerationof etiology.J Neurosurg 1984;61: 143-148. 26. Foo D, RossierAB. Post-traumaticspinal epiduralhematoma.Neurosurgery 1982; 1i: 25-32. 27. KatoS, Seki H, Koshu K. Acute cervicalspinalepiduralhematomawith spontaneousresolution:case report. Neurol Med Clair(Tokyo) 1994;34: 23 26. 28. Fox MW, OnfrioBM, KilgoreJE. Neurologicalcomplicationsof ankylosing spondylitis. J Neurosurg 1993;78: 871-878. 29. Hunter3",Dubo HIC. Spinal fracturescomplicatingankylosingspondylitis. A long term follow-up study. ArthritisRheum 1983; 26: 751-759.
Pseudoaneurysm of anterior communicating artery following transsphenoidal surgery for craniopharyngioma A. Malik 1 MD, M. Goyal I MD, N. K. Mishra 1 MD, A. Verma 2 ach~ S. G a i k w a d 1 MD, V. S. Mehta 2 ach Departments of 1Neuroradiologyand 2Neurosurgery,Neuroseiences Centre, All India Institute of Medical Sciences, New Delhi, India 110 029
Summary Fusiform dilatation and pseudoaneurysm formation in arteries of the circle of Willis has been reported as a complication following surgery for craniopharyngiomas through craniotomies. We present a case of anterior communicating artery pseudoaneurysm following transsphenoidal surgery for craniopharygioma in an adult.
463
CASE REPORT A 26-year-old male patient was admitted with complaints of painless, progressive visual deterioration of 2 months' duration. There were no symptoms to suggest raised intracranial tension or hormonal dysfunction. The visual acuity was 6/9 on the right side and 6/36 on the left side. Examination of the left eye revealed primary optic atrophy and left temporal field cut off. Fundus examination and field charting of the right eye were normal. The sella was enlarged on skull roentgenogram. Preoperative magnetic resonance imaging (MRI) scan of the brain (Fig. 1) showed a large sellar mass with suprasellar extension. The mass was isointense to water on Tl-weighted imaging (T1WI) (TR 450 ms, TE 20 ms, NEX 3) and hyperintense on T2WI (TR 2705 ms, TE 90 ms, NEX 1). There was no evidence of encasement of the arteries of circle of Willis. The optic chiasm was elevated and compressed. The rest of the brain parenchyma was normal. Sublabial transsphenoidal surgery was performed. The patient had profuse bleeding from the operative site soon after the cystic mass was punctured. The contents of the cystic mass simulated 'machine oil' with few cholesterol crystals, consistent with the usual contents of a craniopharyngioma cyst. The bleeding was controlled by packing the sellar floor; complete excision of the tumour was not possible. On the third postoperative day the patient developed profuse cerebrospinal fluid rhinorrhoea necessitating reexploration. At surgery, through the transsphenoidal route, a small hole was seen in the diaphragma which was sealed with autologous fascia and biological glue; the postoperative course was uneventful. Postoperative non-enhanced computed tomography (CT) scan (Fig. 2) showed hyperdensity, suggestive of blood, in the tumour bed with left anterior cerebral artery (ACA) territory infarct involving the left basifrontal lobe and left caudate head. Intraarterial DSA performed 2 days after surgery (Fig. 3) showed spasm in the A1 segment of left ACA with a small AComA pseudoaneurysm. No other arterial abnormality was noted. Repeat DSA study performed after 3 months revealed the pseudoaneurysm to have enlarged in size (Fig. 4). The patient underwent left pterional craniotomy. At surgery the A I segment of left ACA was seen dipping into the sella along with a large pseudoaneurysm of the A C o m A which was successfully clipped.
Journal of Clinical Neuroscience (1998)5(4), 463-464 © HarcourtBrace& Co. Ltd 1998
Keywords : craniopharyngioma, magnetic resonance imaging, pseudoaneurysm, angiography, transsphenoidal surgery Received 22 October 1996 Accepted 10 December 1996 Correspondence to: Dr M. Goyal, Tel: 91 11 6594418, Fax: 91 11 6862663, E-mail: [email protected]
DISCUSSION Craniopharyngiomas are slow growing benign tumours arising from remnants of Rathke's pouch; 70% are both suprasellar and intrasellar in location, while 20% are located solely in the suprasellar region. The most common obstacle to the total removal of craniopharyngioma is dense adhesion to major arteries, usually of the circle of Willis, and lack of a clear plane of cleavage.
INTRODUCTION We report a case of anterior communicating artery (AcomA) pseudoaneurysm in an adult following transsphenoidal decompression of a craniopharyngioma. Histologically benign craniopharyngiomas usually produce symptoms by their growth within the sella and suprasellar cistern. Complete excision, although desired, is not always accomplished due to adhesion of the tumour to the adventitia of vessels in the circle of Willis. 1Fusiform dilatation and pseudoaneurysm formation in the supraclinoid internal carotid artery has been reported as a complication of surgical resection of craniopharyngioma through craniotomies. 2-~ However, AComA pseudoaneurysm formation following transsphenoidal surgery for craniopharyngioma has not been previously reported.
© Harcourt Brace & Co. Ltd 1998
Fig. 1 Preoperative T2-weighted coronal (A) and sagittal (B) MR image (TR 2705 ms, TE 90 ms) showing a large sellar and suprasellar mass with parasellar extension. No arterial abnormality is seen in the circle of Willis.
Joumal of Clinical Neuroscience (1998) 5(4)
464
Malik et al
Fig. 2 Non-contrast enhanced CT scan, immediate postoperative period showed a focal, hyperdense area in the turnout bed suggestive of blood. Also note the left ACA territory infarct.
Fig. 3 Frontal projection of left internal carotid angiogram done in the early postoperative period shows spasm of A1 segment of left ACA with small AComA aneurysm.
Fig. 4 Left internal carotid angiogram after 3 months. Frontal (A) and right oblique (B) projection shows large pseudoaneurysm arising from anterior communicating artery. The A1 segment is seen convex downward possibly due to traction by collapsed roof of the tumour.
Although surgery can be done through craniotomy, the transsphenoidal approach permits removal of mass lesions that are primarily cystic and associated with an enlarged sella. ~ The carotid arteries may be lacerated, perforated, avulsed or damaged secondary to removal of a densely adherent portion of tumour from the wall of the vessel leading to intraoperative tear, postoperative fusiform dilation or pseudoaneurysm formation. 1 Sutton et al reported that 9% of their 31 patients undergoing surgery for craniopharyngioma developed dilatation of the supraclinoid internal carotid artery (ICA) within 4 - 7 months after the initial surgery. Their patients underwent right frontotemporal craniotomy and developed ipsilateral fusiform dilatation of the supraclinoid ICA. 2 Liu reported a case of a right fronto-temporoparietal craniotomy performed for a large suprasellar craniopharyngioma who developed fusiform dilatation of the ipsilateral supraclinoid ICA? According to Sutton and Liu these were true and not pseudoaneurysms. Lakhanpal et al reported two paediatric cases of postoperative aneurysmal dilatation of the supraclinoid carotid arteries following surgical excision of a craniopharyngioma. However, according to them, these were pseudoaneurysms rather than true aneurysms?
Joumal of Clinical Neuroscience (1998) 5(4)
In contrast to all previous reports, our patient underwent transsphenoidal surgery for resection of craniopharyngioma. There was no evidence of arterial abnormality on the preoperative radiological investigation. There was definite arterial injury during surgery as there was profuse bleeding at the operative site as soon as the cystic mass was punctured. A postoperative angiogram showed a pseudoaneurysm of the AComA, which is a relatively unlikely site of direct arterial injury in the transsphenoidal approach. We feel that traction produced by descent of the roof of the tumour cyst after its puncture was the cause of pseudoaneurysm formation; this view was also offered as the likely mechanism in formation of the AComA aneurysm following transsphenoidal surgery for pituitary adenoma as reported by Tsuchida et al. 6 Mycotic aneurysm formation in the supraclinoid ICA following transsphenoidal surgery has been reported in the past] However, in the present case, there was no evidence on imaging or surgery to suggest an infective aetiology. The role of postoperative radiation in aneurysm formation, administered to patients with incompletely resected craniopharyngioma or suprasellar germinomas, is.not clear, although there are reports of such incidents in the past. 4 No radiation, however, was given in our case. Arterial injury to the supraclinoid ICA have been documented previously, z3'5 However, to the best of our knowledge, no case has been reported of A C o m A pseudoaneurysm formation following surgery for craniopharyngioma. This case was furthermore unique since all previous cases described were following craniotomies (frontotemporal 2 or frontotemporoparietal 3) while in our case the transsphenoidal approach was used. Also, in the previously reported cases the mechanism of injury (direct injury or due to traction) could not be discerned clearly due to the location of aneurysm and the surgical approach. To conclude, this case supports the need for careful postoperative follow-up in all age groups where an attempt has been made for complete excision of craniopharyngioma be it either through craniotomy or through the transsphenoidal route.
REFERENCES
1. LitofskyNS, Levy ML, ApuzzoMLJ. Craniopharyngioma.In: ApuzzoMLJ (ed). Brain Surgery.New York: ChurchillLivingstone,1993:313-318. 2. SuttonLN, GusnardD, Bruce DA, Fried A, PackerR, ZimmermanRA. Fusiform dilatationsof the carotid arteryfollowingradicalsurgeryof childhood craniopharyngiomas.J Neurosurg 1991;74: 695-700. 3. Liu SS, ZabramsldJM, SpetzlerRE Fnsiformaneurysmafter surgeryfor craniopharyngioma.J Neurosurg 1991;75:670-71. 4. AzzarelliB, MooreJ, GilmoreR, MullerJ, EdwardsM, MealeyJ. Multiple fusiformintracranialaneurysmsfollowingcurativeradiationtherapyfor suprasellargerminoma.J Neurosurg 1984; 61: 1141-1145. 5. LakhanpalSK, GlasierCM, James CA, AntuacoEJC. MR and CT diagnosisof carotid pseudoaneurysmin childrenfollowingsurgicalresectionof craniopharyngioma.PediatrRadiol 1995; 25:249-251. 6. TsuchidaT, TanakaR, YokoyamaM, Sato H. Ruptureof anterior communicatingartery duringtranssphenoidalsurgeryfor pituitaryadenoma. Surg Neurol 1983;20: 67-70. 7. OnishiH, Ito H, KurudaE et al. Intracranialmycoticaneurysmassociatedwith transsphenoidalsurgeryto the pituitaryadenoma.Surg Neurol1989; 3 l: 149-154.
© Harcourt Brace & Co. Ltd 1998
21. GundryLR, HeithoffKB. Epiduralhematomaof the lumbarspine: 18 surgicallyconfirmedcases. Radiology 1993; 187:427~43i. 22. LobitzB, GrateI. Acute epiduralhematomaof the cervicalspine: an unusual cause of neck pain. SouthMed J 1995; 88(5): 580-582. 23. MannaJW, Bail MR, Lee KS, McWhorterJM. Spontaneousspinal epidural hematomacomplicatingPaget's disease of the spine. Spine 1995; 14(8): 900-902. 24. CooperDW. Spontaneousspinal epiduralhematoma. J Neurosurg 1967; 26: 343 346. 25. BeattyRM, WinstonKR. Spontaneouscervicalepiduralhematoma.A considerationof etiology.J Neurosurg 1984;61: 143-148. 26. Foo D, RossierAB. Post-traumaticspinal epiduralhematoma.Neurosurgery 1982; 1i: 25-32. 27. KatoS, Seki H, Koshu K. Acute cervicalspinalepiduralhematomawith spontaneousresolution:case report. Neurol Med Clair(Tokyo) 1994;34: 23 26. 28. Fox MW, OnfrioBM, KilgoreJE. Neurologicalcomplicationsof ankylosing spondylitis. J Neurosurg 1993;78: 871-878. 29. Hunter3",Dubo HIC. Spinal fracturescomplicatingankylosingspondylitis. A long term follow-up study. ArthritisRheum 1983; 26: 751-759.
Pseudoaneurysm of anterior communicating artery following transsphenoidal surgery for craniopharyngioma A. Malik 1 MD, M. Goyal I MD, N. K. Mishra 1 MD, A. Verma 2 ach~ S. G a i k w a d 1 MD, V. S. Mehta 2 ach Departments of 1Neuroradiologyand 2Neurosurgery,Neuroseiences Centre, All India Institute of Medical Sciences, New Delhi, India 110 029
Summary Fusiform dilatation and pseudoaneurysm formation in arteries of the circle of Willis has been reported as a complication following surgery for craniopharyngiomas through craniotomies. We present a case of anterior communicating artery pseudoaneurysm following transsphenoidal surgery for craniopharygioma in an adult.
463
CASE REPORT A 26-year-old male patient was admitted with complaints of painless, progressive visual deterioration of 2 months' duration. There were no symptoms to suggest raised intracranial tension or hormonal dysfunction. The visual acuity was 6/9 on the right side and 6/36 on the left side. Examination of the left eye revealed primary optic atrophy and left temporal field cut off. Fundus examination and field charting of the right eye were normal. The sella was enlarged on skull roentgenogram. Preoperative magnetic resonance imaging (MRI) scan of the brain (Fig. 1) showed a large sellar mass with suprasellar extension. The mass was isointense to water on Tl-weighted imaging (T1WI) (TR 450 ms, TE 20 ms, NEX 3) and hyperintense on T2WI (TR 2705 ms, TE 90 ms, NEX 1). There was no evidence of encasement of the arteries of circle of Willis. The optic chiasm was elevated and compressed. The rest of the brain parenchyma was normal. Sublabial transsphenoidal surgery was performed. The patient had profuse bleeding from the operative site soon after the cystic mass was punctured. The contents of the cystic mass simulated 'machine oil' with few cholesterol crystals, consistent with the usual contents of a craniopharyngioma cyst. The bleeding was controlled by packing the sellar floor; complete excision of the tumour was not possible. On the third postoperative day the patient developed profuse cerebrospinal fluid rhinorrhoea necessitating reexploration. At surgery, through the transsphenoidal route, a small hole was seen in the diaphragma which was sealed with autologous fascia and biological glue; the postoperative course was uneventful. Postoperative non-enhanced computed tomography (CT) scan (Fig. 2) showed hyperdensity, suggestive of blood, in the tumour bed with left anterior cerebral artery (ACA) territory infarct involving the left basifrontal lobe and left caudate head. Intraarterial DSA performed 2 days after surgery (Fig. 3) showed spasm in the A1 segment of left ACA with a small AComA pseudoaneurysm. No other arterial abnormality was noted. Repeat DSA study performed after 3 months revealed the pseudoaneurysm to have enlarged in size (Fig. 4). The patient underwent left pterional craniotomy. At surgery the A I segment of left ACA was seen dipping into the sella along with a large pseudoaneurysm of the A C o m A which was successfully clipped.
Journal of Clinical Neuroscience (1998)5(4), 463-464 © HarcourtBrace& Co. Ltd 1998
Keywords : craniopharyngioma, magnetic resonance imaging, pseudoaneurysm, angiography, transsphenoidal surgery Received 22 October 1996 Accepted 10 December 1996 Correspondence to: Dr M. Goyal, Tel: 91 11 6594418, Fax: 91 11 6862663, E-mail: [email protected]
DISCUSSION Craniopharyngiomas are slow growing benign tumours arising from remnants of Rathke's pouch; 70% are both suprasellar and intrasellar in location, while 20% are located solely in the suprasellar region. The most common obstacle to the total removal of craniopharyngioma is dense adhesion to major arteries, usually of the circle of Willis, and lack of a clear plane of cleavage.
INTRODUCTION We report a case of anterior communicating artery (AcomA) pseudoaneurysm in an adult following transsphenoidal decompression of a craniopharyngioma. Histologically benign craniopharyngiomas usually produce symptoms by their growth within the sella and suprasellar cistern. Complete excision, although desired, is not always accomplished due to adhesion of the tumour to the adventitia of vessels in the circle of Willis. 1Fusiform dilatation and pseudoaneurysm formation in the supraclinoid internal carotid artery has been reported as a complication of surgical resection of craniopharyngioma through craniotomies. 2-~ However, AComA pseudoaneurysm formation following transsphenoidal surgery for craniopharyngioma has not been previously reported.
© Harcourt Brace & Co. Ltd 1998
Fig. 1 Preoperative T2-weighted coronal (A) and sagittal (B) MR image (TR 2705 ms, TE 90 ms) showing a large sellar and suprasellar mass with parasellar extension. No arterial abnormality is seen in the circle of Willis.
Joumal of Clinical Neuroscience (1998) 5(4)
464
Malik et al
Fig. 2 Non-contrast enhanced CT scan, immediate postoperative period showed a focal, hyperdense area in the turnout bed suggestive of blood. Also note the left ACA territory infarct.
Fig. 3 Frontal projection of left internal carotid angiogram done in the early postoperative period shows spasm of A1 segment of left ACA with small AComA aneurysm.
Fig. 4 Left internal carotid angiogram after 3 months. Frontal (A) and right oblique (B) projection shows large pseudoaneurysm arising from anterior communicating artery. The A1 segment is seen convex downward possibly due to traction by collapsed roof of the tumour.
Although surgery can be done through craniotomy, the transsphenoidal approach permits removal of mass lesions that are primarily cystic and associated with an enlarged sella. ~ The carotid arteries may be lacerated, perforated, avulsed or damaged secondary to removal of a densely adherent portion of tumour from the wall of the vessel leading to intraoperative tear, postoperative fusiform dilation or pseudoaneurysm formation. 1 Sutton et al reported that 9% of their 31 patients undergoing surgery for craniopharyngioma developed dilatation of the supraclinoid internal carotid artery (ICA) within 4 - 7 months after the initial surgery. Their patients underwent right frontotemporal craniotomy and developed ipsilateral fusiform dilatation of the supraclinoid ICA. 2 Liu reported a case of a right fronto-temporoparietal craniotomy performed for a large suprasellar craniopharyngioma who developed fusiform dilatation of the ipsilateral supraclinoid ICA? According to Sutton and Liu these were true and not pseudoaneurysms. Lakhanpal et al reported two paediatric cases of postoperative aneurysmal dilatation of the supraclinoid carotid arteries following surgical excision of a craniopharyngioma. However, according to them, these were pseudoaneurysms rather than true aneurysms?
Joumal of Clinical Neuroscience (1998) 5(4)
In contrast to all previous reports, our patient underwent transsphenoidal surgery for resection of craniopharyngioma. There was no evidence of arterial abnormality on the preoperative radiological investigation. There was definite arterial injury during surgery as there was profuse bleeding at the operative site as soon as the cystic mass was punctured. A postoperative angiogram showed a pseudoaneurysm of the AComA, which is a relatively unlikely site of direct arterial injury in the transsphenoidal approach. We feel that traction produced by descent of the roof of the tumour cyst after its puncture was the cause of pseudoaneurysm formation; this view was also offered as the likely mechanism in formation of the AComA aneurysm following transsphenoidal surgery for pituitary adenoma as reported by Tsuchida et al. 6 Mycotic aneurysm formation in the supraclinoid ICA following transsphenoidal surgery has been reported in the past] However, in the present case, there was no evidence on imaging or surgery to suggest an infective aetiology. The role of postoperative radiation in aneurysm formation, administered to patients with incompletely resected craniopharyngioma or suprasellar germinomas, is.not clear, although there are reports of such incidents in the past. 4 No radiation, however, was given in our case. Arterial injury to the supraclinoid ICA have been documented previously, z3'5 However, to the best of our knowledge, no case has been reported of A C o m A pseudoaneurysm formation following surgery for craniopharyngioma. This case was furthermore unique since all previous cases described were following craniotomies (frontotemporal 2 or frontotemporoparietal 3) while in our case the transsphenoidal approach was used. Also, in the previously reported cases the mechanism of injury (direct injury or due to traction) could not be discerned clearly due to the location of aneurysm and the surgical approach. To conclude, this case supports the need for careful postoperative follow-up in all age groups where an attempt has been made for complete excision of craniopharyngioma be it either through craniotomy or through the transsphenoidal route.
REFERENCES
1. LitofskyNS, Levy ML, ApuzzoMLJ. Craniopharyngioma.In: ApuzzoMLJ (ed). Brain Surgery.New York: ChurchillLivingstone,1993:313-318. 2. SuttonLN, GusnardD, Bruce DA, Fried A, PackerR, ZimmermanRA. Fusiform dilatationsof the carotid arteryfollowingradicalsurgeryof childhood craniopharyngiomas.J Neurosurg 1991;74: 695-700. 3. Liu SS, ZabramsldJM, SpetzlerRE Fnsiformaneurysmafter surgeryfor craniopharyngioma.J Neurosurg 1991;75:670-71. 4. AzzarelliB, MooreJ, GilmoreR, MullerJ, EdwardsM, MealeyJ. Multiple fusiformintracranialaneurysmsfollowingcurativeradiationtherapyfor suprasellargerminoma.J Neurosurg 1984; 61: 1141-1145. 5. LakhanpalSK, GlasierCM, James CA, AntuacoEJC. MR and CT diagnosisof carotid pseudoaneurysmin childrenfollowingsurgicalresectionof craniopharyngioma.PediatrRadiol 1995; 25:249-251. 6. TsuchidaT, TanakaR, YokoyamaM, Sato H. Ruptureof anterior communicatingartery duringtranssphenoidalsurgeryfor pituitaryadenoma. Surg Neurol 1983;20: 67-70. 7. OnishiH, Ito H, KurudaE et al. Intracranialmycoticaneurysmassociatedwith transsphenoidalsurgeryto the pituitaryadenoma.Surg Neurol1989; 3 l: 149-154.
© Harcourt Brace & Co. Ltd 1998