Carotid Artery Injury during Endoscopic Endonasal Pituitary Surgery: A Report of Two Cases

Abstract

We present two cases of successful hemostasis in patients with a re-enlarged pituitary adenoma who had intraoperative bleeding from the internal carotid artery during endoscopic endonasal pituitary surgery. Case 1 involved a woman in her sixties who suffered bleeding from the left internal carotid artery. The hemorrhage was controlled by applying direct pressure using cottonoids, followed by pieces of oxidized cellulose soaked in fibrinogen solution. Postoperative magnetic resonance angiography revealed a pseudoaneurysm, and the internal carotid artery was subsequently embolized with coils. Following a balloon occlusion test that indicated borderline ischemic tolerance, a superficial temporal-middle cerebral artery anastomosis was performed. Case 2 involved a man in his eighties who experienced bleeding from the left internal carotid artery during tumor removal using an ultrasonic surgical aspirator. Hemostasis was achieved by focal pressure using cottonoids, followed by insertion into the bleeding site of a crushed muscle patch taken from the thigh. Postoperative cerebral angiography identified a small pseudoaneurysm, and coil embolization of the internal carotid artery was performed without additional surgical procedures, as a balloon occlusion test showed ischemia tolerance. Both patients were discharged home without any additional neurological deficits. These cases show that initial control of bleeding from the internal carotid artery can be achieved through focal pressure using cottonoids, followed by compression hemostasis utilizing a crushed muscle patch. In cases in which a pseudoaneurysm arises at the site of injury, complete interruption of blood flow in the internal carotid artery through coil embolization should be immediately performed while considering the patient’s cerebral ischemic tolerance. This necessitates seamless collaboration among rhinologists, neurosurgeons, anesthesiologists, and nursing staff.