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      Intracranial Intradural Vascular Injury during Endoscopic Endonasal Transsphenoidal Surgery: A Case Report and Literature Review

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          Abstract

          Background  Transsphenoidal surgery (TSS) is a procedure for sellar or midline masses in the skull base. Among the reported complications are iatrogenic vascular injuries; that are rare, yet they carry devastating outcomes, with an incidence of injury between 0.34 and 2.6%. The cavernous internal carotid artery is the most commonly injured. However, intradural arterial injuries are much less reported with challenging management. We report a rare incident of intradural arterial injury during TSS, and we compared our management to the summarized few cases reported in the literature

          Case Report  We report a 43-year-old female who had a recurrent planum sphenoidal meningioma. She underwent trans-nasal transsphenoidal endoscopic resection that was complicated with intraoperative bleeding due to an injury to the anterior communicating artery that was challenging to control, resulted in a bilateral loss of flow in A1 segments of anterior cerebral artery and required endovascular management. The patient had a good recovery postoperatively without the typical picture of ACA syndrome.

          Conclusion  Intradural arterial injury is exceedingly rare in TSS, with no clear standard of care for the management. Collateral blood supply allows definitive management with minimal morbidity. Identifying the risk factors beforehand, as well as performing such cases in a well-resourced center, are crucial elements of safety.

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          Blood pressure and clinical outcomes in the International Stroke Trial.

          Peter A G Sandercock, Robert Phillips, … (2002)
          Among patients with acute stroke, high blood pressure is often associated with poor outcome, although the reason is unclear. We analyzed data from the International Stroke Trial (IST) to explore the relationship between systolic blood pressure (SBP), subsequent clinical events over the next 2 weeks, and functional outcome at 6 months in patients with acute stroke. We included in the analysis 17 398 patients from IST with confirmed ischemic stroke. A single measurement of SBP was made immediately before randomization. Clinical events within 14 days of randomization were recorded: recurrent ischemic stroke, symptomatic intracranial hemorrhage, death resulting from presumed cerebral edema, fatal coronary heart disease, and death. Survival and dependency were assessed at 6 months. Outcomes were adjusted for age, sex, clinical stroke syndrome, time to randomization, consciousness level, atrial fibrillation, and treatment allocation (aspirin, unfractionated heparin, both, or neither). A U-shaped relationship was found between baseline SBP and both early death and late death or dependency: early death increased by 17.9% for every 10 mm Hg below 150 mm Hg (P<0.0001) and by 3.8% for every 10 mm Hg above 150 mm Hg (P=0.016). The rate of recurrent ischemic stroke within 14 days increased by 4.2% for every 10-mm Hg increase in SBP (P=0.023); this association was present in both fatal and nonfatal recurrence. Death resulting from presumed cerebral edema was independently associated with high SBP (P=0.004). No relationship between symptomatic intracranial hemorrhage and SBP was seen. Low SBP was associated with a severe clinical stroke (total anterior circulation syndrome) and an excess of deaths from coronary heart disease (P=0.002). Both high blood pressure and low blood pressure were independent prognostic factors for poor outcome, relationships that appear to be mediated in part by increased rates of early recurrence and death resulting from presumed cerebral edema in patients with high blood pressure and increased coronary heart disease events in those with low blood pressure. The occurrence of symptomatic intracranial hemorrhage within 14 days was independent of SBP.
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            U-shaped relationship between mortality and admission blood pressure in patients with acute stroke.

            K N Vemmos, G. Tsivgoulis, K Spengos … (2004)
            To evaluate the relationship between systolic blood pressure (SBP) or diastolic blood pressure (DBP) on admission and early or late mortality in patients with acute stroke. Prospective study of hospitalized first-ever stroke patients over 8 years. Stroke unit and medical wards in a University hospital. A total of 1121 patients admitted within 24 h from stroke onset and followed up for 12 months. Mortality at 1 and 12 months after stroke in relation to admission SBP and DBP. Early and late mortality in patients with acute ischaemic or haemorrhagic stroke in relation to admission SBP and DBP followed a 'U-curve pattern'. After adjusting for known outcome predictors, the relative risk of 1-month and 1-year mortality associated with a 10-mmHg SBP increase above 130 mmHg (U-point of the curve) increased by 10.2% (95% CI: 4.2-16.6%) and 7.2% (95% CI: 2.2-12.3%), respectively. For every 10 mmHg SBP decrease, below the U-point, the relative risk of 1-month and 1-year mortality rose by 28.2% (95% CI: 8.6-51.3%) and 17.5% (95% CI: 3.1-34.0%), respectively. Low admission SBP-values were associated with heart failure (P < 0.001) and coronary artery disease (P = 0.006), whilst high values were associated with history of hypertension (P < 0.001) and lacunar stroke (P < 0.001). Death due to cerebral oedema was significantly (P = 0.005) more frequent in patients with high admission SBP-values, whereas death due to cardiovascular disease was more frequent (P = 0.004) in patients with low admission SBP-values. Acute ischaemic or haemorrhagic stroke patients with high and low admission BP-values have a higher early and late mortality. Coincidence of heart disease is associated with low initial BP-values. Death due to neurological damage from brain oedema is associated with high initial BP-values.
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              Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients.

              A Kassam, Paul Gardner, Carl H Snyderman … (2011)
              The development of endoscopic endonasal approaches, albeit in the early stages, represents part of the continuous evolution of skull base surgery. During this early period, it is important to determine the safety of these approaches by analyzing surgical complications to identify and eliminate their causes. The authors reviewed all perioperative complications associated with endoscopic endonasal skull base surgeries performed between July 1998 and June 2007 at the University of Pittsburgh Medical Center. This study includes the data for the authors' first 800 patients, comprising 399 male (49.9%) and 401 female (50.1%) patients with a mean age of 49.21 years (range 3-96 years). Pituitary adenomas (39.1%) and meningiomas (11.8%) were the 2 most common pathologies. A postoperative CSF leak represented the most common complication, occurring in 15.9% of the patients. All patients with a postoperative CSF leak were successfully treated with a lumbar drain and/or another endoscopic approach, except for 1 patient who required a transcranial repair. The incidence of postoperative CSF leaks decreased significantly with the adoption of vascularized tissue for reconstruction of the skull base (< 6%). Transient neurological deficits occurred in 20 patients (2.5%) and permanent neurological deficits in 14 patients (1.8%). Intracranial infection and systemic complications were encountered and successfully treated in 13 (1.6%) and 17 (2.1%) patients, respectively. Seven patients died during the 30-day perioperative period, 6 of systemic illness and 1 of infection (overall mortality 0.9%). Endoscopic endonasal skull base surgery provides a viable median corridor based on anatomical landmarks and is customized according to the specific pathological process. This corridor should be considered as the sole access or may be combined with traditional approaches. With the incremental acquisition of skills and experience, endoscopic endonasal approaches have an acceptable safety profile in select patients presenting with various skull base pathologies.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Neurol Surg Rep
                Journal ID (iso-abbrev): J Neurol Surg Rep
                Journal ID (doi): 10.1055/s-00000182
                Title: Journal of Neurological Surgery Reports
                Publisher: Georg Thieme Verlag KG (Stuttgart · New York )
                ISSN (Print): 2193-6358
                ISSN (Electronic): 2193-6366
                Publication date (Print): July 2020
                Publication date (Electronic): 24 September 2020
                Volume: 81
                Issue: 3
                Pages: e52-e58
                Affiliations
                [1 ]Department of Surgery, Division of Neurosurgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
                [2 ]Department of Otolaryngology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
                [3 ]Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
                Author notes
                Address for correspondence Abdulrazag Ajlan, MD, FRCSC Department of Neurosurgery, King Khalid University Hospital, King Saud University RiyadhSaudi Arabia Dr_Ajlan79@ 123456Hotmail.com
                Mailing Address: Department of Surgery, College of Medicine, King Saud University KKUH Riyadh 11472, P.O.Box 7805 (37)
                Author information
                http://orcid.org/0000-0002-4709-795X
                http://orcid.org/0000-0002-3053-7912
                Article
                Publisher ID: 200002
                DOI: 10.1055/s-0040-1717056
                PMC ID: 7515681
                SO-VID: 42a98e65-f07e-4569-a33e-511948986936
                Copyright © The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

                History
                Date received : 14 February 2020
                Date accepted : 25 June 2020
                Categories
                Subject: Case Report

                Keywords: vascular injury,endoscopic endonasal approach,endovascular,intradural,complication
                Data availability:
                Keywords: vascular injury, endoscopic endonasal approach, endovascular, intradural, complication

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