====== Posterior communicating artery injury ======

[[Intracranial]] [[pseudoaneurysm]] is a rare [[complication]] of [[endoscopic endonasal surgery]]. Herein, Morinaga et al., from [[Fukuoka University Chikushi Hospital]] describe two-staged [[stent assisted coil embolization]] for [[posterior communicating artery pseudoaneurysm]] after [[endoscopic endonasal surgery]] for [[pituitary neuroendocrine tumor]].

A 68-year-old man had a history of severe adult [[growth hormone]] secretion deficiency, requiring growth [[hormone replacement therapy]]; secondary [[adrenal hypofunction]]; [[hyperthyroidism]]; [[hypertension]]; [[constipation]]; [[glaucoma]]; and [[hyperuricemia]]. Five years ago, after initial endoscopic [[transsphenoidal surgery]] for [[pituitary neuroendocrine tumor]], he was hospitalized for [[reoperation]]. [[Posterior communicating artery]] injury was observed during second endoscopic trans-sphenoidal surgery and pressure hemostasis was performed using a hemostatic preparation. Immediately post-surgery, a localized [[subarachnoid hemorrhage]] was observed. Sudden-onset impaired [[consciousness]] and respiratory disturbances ensued on postoperative day 7, and computed tomography of the head was performed. Recurrent subarachnoid hemorrhage was confirmed, and [[acute hydrocephalus]] secondary to third ventricular blockage was identified. [[Cerebral angiography]] was performed after urgent bilateral cerebral [[ventricular drainage]] under [[general anesthesia]]. A [[pseudoaneurysm]] was identified in the left posterior communicating artery, and [[coil embolization]] was performed. Six weeks post-surgery, [[LVIS]]® Jr. [[stent]] was placed in the posterior communicating artery. Recurrence of the aneurysm was not detected 6 months post-surgery. He underwent [[lumboperitoneal shunt]]ing for secondary [[normal pressure hydrocephalus]] after [[dual antiplatelet therapy]] discontinuation and is being followed-up as an outpatient with a [[modified Rankin Scale]] of 2 10 months post-surgery.

Two-staged stent-assisted coil embolization using LVIS® stent was effective for a posterior communicating artery pseudoaneurysm occurring after [[posterior communicating artery injury]] following endoscopic trans-sphenoidal surgery for [[Follicle stimulating hormone secreting pituitary neuroendocrine tumor]]
((Morinaga Y, Nii K, Sakamoto K, Inoue R, Mitsutake T, Hanada H. Stent-assisted 
Coil Embolization for a Ruptured Posterior Communicating Artery Pseudoaneurysm
after Endoscopic Trans-sphenoidal Surgery for pituitary neuroendocrine tumor. World Neurosurg.
2018 Dec 21. pii: S1878-8750(18)32870-5. doi: 10.1016/j.wneu.2018.12.047. [Epub
ahead of print] PubMed PMID: 30583130.
)).
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Traumatic injury of the [[posterior communicating artery]] or the basilar artery causing arteriovenous fistulae is rare.

Ko et al., report an unusual case of the coincidence of a posterior communicating artery-cavernous sinus fistula and a basilar artery-cavernous sinus fistula associated with traumatic pseudoaneurysms of the posterior communicating and basilar arteries. The fistulas and pseudoaneurysms were obliterated completely after staged endovascular surgery via a transarterial and transvenous route.

This is the first such report worldwide
((Ko HC, Koh JS, Shin HS, Lee SH, Ryu CW. Staged Endovascular Occlusion of a
Posterior Communicating Artery-Cavernous Sinus Fistula and a Basilar
Artery-Cavernous Sinus Fistula Associated with Traumatic Pseudoaneurysms:
Technical Consideration and Literature Review. World Neurosurg. 2017
Nov;107:1051.e7-1051.e11. doi: 10.1016/j.wneu.2017.08.070. Epub 2017 Aug 24.
Review. PubMed PMID: 28842235.
)).
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A middle-aged patient presented with a rapidly growing right dural-based extra-axial posterior clinoid mass extending to the right cavernous sinus that was surgically resected. Histological examination showed solid growth of primitive neuroectodermal tumor arising from the third nerve. Following surgical resection, the patient was further managed by radiation and chemotherapy. Two years later the patient developed new intracranial hemorrhage in the area adjacent to the previous surgical cavity. A cerebral angiogram showed contrast extravasation at the junction of the posterior communicating artery (Pcom) and the right posterior cerebral artery (PCA), with an expanding pseudoaneurysm. This was managed with N-butyl cyanoacrylate embolization. Autopsy showed microscopic recurrence of tumor into the PCA/PCom region with invasion of the wall of the Pcom. This case report illustrates the concept of vascular blowout in intracranial cerebral vasculature. It appears that, in the presence of risk factors that contribute to weakening of vessel walls (surgery, radiation, tumor recurrence), a blowout can occur intracranially
((Alaraj A, Behbahani M, Valyi-Nagy T, Aardsma N, Aletich VA. Rare presentation 
of intracranial vascular blowout after tumor resection and radiation therapy. J
Neurointerv Surg. 2015 May;7(5):e18. doi: 10.1136/neurintsurg-2014-011192.rep.
Epub 2014 Apr 24. PubMed PMID: 24763549.
)).