Internal Carotid Artery Injury During the Endoscopic Transsphenoidal Surgery of Pituitary Adenoma: Case Illustration, Introspection, and Systematic Review.

Advances in endoscopic technology have made the endoscopic transsphenoidal approach the preferred approach for most surgeries of pituitary adenoma. The goal of these surgeries is to achieve cure, efficacy, and safety. Ample research has deliberated on the complications of cerebrospinal fluid (CSF) leak, meningitis, visual deterioration and nasal crusting after endoscopic transsphenoidal surgery. Among these, injury to the internal carotid artery (ICA) is not common in transsphenoidal pituitary surgery and has an incidence that ranges from 0.1% to 1%. Though it is rare, the effects are devastating and associated with a high risk of mortality and morbidity. As a result, iatrogenic ICA injury is every neurosurgeon's nightmare. Available literature primarily consists of case reports on these injuries. The literature is lacking on preventive and management options. We present an unusual case of a patient who had a nonfunctioning pituitary macroadenoma and an unexpected injury to the internal carotid artery (ICA) during endoscopic transsphenoidal surgery. We share our successful experience with its management via emergency endovascular treatment with parent vessel occlusion for an iatrogenic ICA injury. We present the article to address the pragmatic questions and challenges faced by neurosurgeons experiencing this complication for the first time.