PMC9127310_01
Preoperative coronal (A) and sagittal (B) T2-weighted magnetic resonance images showing a pituitary tumor as slight hyperintensity, compressing the optic nerve.
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F1
T1-weighted imaging, slight hyperintensity on T2-weighted imaging, and compressed the optic nerve assessed as Knosp grade 2 (Figure 1). The sphenoid sinus appeared as the sellar type with no notable findings.
Intraoperative photographs of the endoscopic transsphenoidal surgery that caused internal carotid artery (ICA) injury. (A) Petrous portion of the left ICA was injured (green arrowheads). (B) Crushed muscle patch was unsuccessfully applied to the injured site (green arrowheads) of the left ICA. (C) Injured site of the left ICA was covered with cotton patties. (D) Surgical field was closed using the right-sided vascularized pedicled nasoseptal flap.
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F2
The petrous portion of the left ICA was injured during resection of the sphenoid septum connected with the left carotid prominence using a cutting forceps (Figure 2A). We then tried to replace the cotton patties over the bleeding site with the crushed muscle patch (Figure 2B). We eventually decided not to use the crushed muscle patch and completed the hemostatic procedure by applying two cotton patties to the bleeding site, followed by fibrin glue coating (Figure 2C). The surgical field was closed using the right-sided vascularized pedicled nasoseptal flap with fibrin glue coating (Figure 2D), followed by fixing with balloon compression.
(A) Three-dimensional cerebral angiography of the left internal carotid artery (ICA) immediately after surgery showing no extravasation from the injured site of the left ICA petrous portion. (B) Three-dimensional cerebral angiography of the left ICA following balloon deflation 7 days after surgery revealing carotid-cavernous sinus fistula (CCF) originating from the injured site of the left ICA petrous portion. (C) Postoperative magnetic resonance angiography showing the success of vascular reconstructive surgery combined with internal coil trapping of the left ICA.
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F3
Cerebral angiography performed immediately after surgery under general anesthesia showed no extravasation from the injured site of the left ICA petrous portion and normal antegrade cerebral hemodynamics (Figure 3A). However, cerebral angiography following balloon deflation 7 days after surgery revealed the presence of a carotid-cavernous sinus fistula (CCF) originating from the injured site of the left ICA petrous portion (Figure 3B). These procedures were successful, and the postoperative course was uneventful (Figure 3C).