Rupture of intracranial aneurysm resulting in subarachnoid hemorrhage is well known to carry significant risk of poor outcome. Intra-operative rupture of an unknown intracranial aneurysm during a neurosurgical procedure is a rare occurrence that can lead to devastating consequences if not recognized and managed appropriately. Here we describe to our knowledge, the first reported case of previously unknown, remote from the surgical site, intra-operative posterior cerebral artery aneurysm rupture during transnasal endoscopic transphenoidal resection of a pituitary macroadenoma, review relevant literature, and discuss strategies to reduce surgical risk and improve patient outcomes.
The relationship between intracranial aneurysms and pituitary adenomas has been well described. Many studies have reported a relationship between these distinct pathologies exists [
A 68-year old woman presented for outpatient neurosurgical consultation with chief complaint of visual loss. She reported several months of declining vision. She was referred for MR imaging which revealed a pituitary macroadenoma with suprasellar extension causing compression of the optic chiasm (
She underwent endoscopic removal of nasal packing on postoperative day 6, and she was discharged to inpatient rehabilitation without further complication on post operative day 12 with persistent third cranial nerve palsy. In followup, the patient’s diplopia resolved within 3 months. At most recent followup, more than 3 years after treatment, she remains without neurological deficit, repeat angiogram is without recurrence of the aneurysm and MRI shows no tumor recurrence (
Many reports have hypothesized a relationship between pituitary adenomas and aneurysms. One study found a 13.8% incidence of IA with growth hormone producing adenomas [
Intra-operative rupture of aneurysms during open aneurismal surgical repair is a well reported complication affecting 6.7% of aneurysms in one retrospective review [
Etiologies of intra-operative ruptures during transphenoidal surgery vary. Direct trauma to an unidentified or hidden aneurysm by surgical instruments can damage aneurysms in the vicinity of the sella. Indirect mechanisms of rupture are largely responsible for remote ruptures such as described in this case report. Etiologies of indirect ruptures include csf egress and changes in trans mural pressure. This is supported by a link between ventricular drainage and aneurysm rupture [
Intra-operative identification of the hemorrhage in our report was possible by viewing a tense, red diaphragm sella with the endoscope. The only other similar case report we could identify was an ACOM aneurysm rupture during macroadenoma resection [
Management of aneurismal rupture during transphenoidal surgery requires identification, hemostasis, and angiography. The minimally invasive opening created during endoscopic surgery becomes an immediate obstacle when faced with vascular complications. All intra-operative ruptures discussed in the literature review and our report were immediately tamponaded by packing the sella. Prompt transport to the angiography suite is necessary as this procedure can be both diagnostic and therapeutic. Use of external ventriculostomy and subarachnoid hemorrhage protocols can then be utilized as necessary after the patient is stabilized. In our study the diaphragm was opened to allow evacuation of the hemorrhage. The hemorrhage was controlled with irrigation and sellar packing. Stat head CT followed by diagnostic angiography and coil embolization ultimately secured the aneurysm.
In the pre-CT and MRI-era angiography was a standard part of the pre-op workup for transphenoidal surgery [
We have reported the first case of remote intra-operative posterior circulation aneurismal rupture during routine endoscopic transphenoidal surgery for a pituitary macroadenoma. Preoperative diagnosis of IA could provide benefit, but evidence is not strong enough to support routine preoperative angiographic screening without identifying any other significant risk factor for IA. Intra-operative identification of aneurismal rupture is important, as continued bleeding and re-rupture can lead to poor outcomes. Identification in this case was possible by viewing a tense, red diaphragm sella. Intra-operative management consists of prompt recognition, irrigation, sellar packing and blood transfusion if necessary. Diagnosis is made with emergent angiography and early treatment with endovascular or open surgical technique is necessary to minimize morbidity.
The authors declare no conflicts of interest. This case was not previously published or presented at National Meetings.