Delayed Carotid Pseudoaneurysms from Iatrogenic Clival Meningeal Branches Avulsion: Recognition and Proposed Management

• Published in: World neurosurgery Vol. 104; pp. 736 - 744
• Main Authors: Almefty, Rami, Dunn, Ian F., Aziz-Sultan, Muhammad Ali, Al-Mefty, Ossama
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.08.2017
• Subjects: Aged; Aneurysm, False - diagnostic imaging; Aneurysm, False - therapy; Angiography, Digital Subtraction; Carotid Artery Injuries - diagnostic imaging; Carotid Artery Injuries - therapy; Carotid Artery, Internal - diagnostic imaging; Carotid injury; Carotid occlusion; Cerebral Angiography; Chordoma - surgery; Clivus; Computed Tomography Angiography; Covered stent; Cranial Fossa, Posterior - surgery; Delayed Diagnosis; Dural artery; Female; Humans; Imaging, Three-Dimensional; Magnetic Resonance Angiography; Male; Meningeal Arteries - diagnostic imaging; Meningeal Arteries - injuries; Meningeal Neoplasms - surgery; Meningioma - surgery; Middle Aged; Neurosurgery; Postoperative Complications - diagnostic imaging; Postoperative Complications - therapy; Pseudoaneurysm; Skull base; Stents; Transsphenoidal; Transsphenoidal; CTA; Carotid occlusion; Skull base; Carotid injury; Covered stent; Clivus; Dural artery; Pseudoaneurysm; ASA; MRI; dural artery; balloon test occlusion; carotid occlusion; DSA; Computed tomography; internal carotid artery; covered stent; three dimensional; ICA; pseudoaneurysm; clivus; digital subtraction angiography; cm; MCA; transsphenoidal; middle cerebral artery; acetylsalicylic acid; Computed tomography angiography; carotid injury; Magnetic Resonance Imaging; CT; 3D; BTO; centimeter
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2017.03.016

Carotid injury during anterior skull base approaches is promptly recognizable and mandates immediate treatment; likewise, development of pseudoaneurysms after such injuries is anticipated and managed. We report here on the delayed development of a pseudoaneurysm as the result of avulsion of clival meningeal arteries that manifests as unalarming intraoperative bleeding. The bleeding is brisk and arterial but easily controlled. Immediate postoperative angiography is negative, necessitating repeated angiography to depict the delayed formation. It is best treated by endovascular means that maintains patency of the carotid artery, calling for the development of a suitable device that obliterates the opening of the pseudoaneurysm while maintaining carotid flow that is deployable in the tortuous carotid artery.