Unexpected internal carotid artery injury during endoscopic transsphenoidal surgery.

Background: Internal carotid artery (ICA) injury is a rare but severe complication of transsphenoidal surgery. Case Description: A 69-year-old woman presented with progressive visual disturbance secondary to pituitary adenoma. The patient underwent subtotal tumor resection through endoscopic transsphenoidal surgery. The residual tumor in the cavernous sinus gradually enlarged over the next 3 years. During a second surgical intervention, an inadvertent scratch, with the worn-out tip of the micro-suction device, on the partially calcified medial wall of the C4 segment resulted in ICA rupture, leading to uncontrollable hemorrhage. After provisional hemostasis, the patient was transported to the angiography suite, where an irregularly shaped leak of contrast on the medial aspect of C4. A stent-assisted coil embolization was successfully performed, resulting in complete aneurysm isolation. The patient underwent revisional surgery on postoperative day (POD) 14, in which the coils exposed from the ICA laceration were covered with fascia lata, muscle, and surgical glue. After a lumboperitoneal shunt placement for progressive hydrocephalus, the patient was discharged on POD 82 without focal neurological deficits. Conclusion: During transsphenoidal surgery, ICA injury can result from inadvertent manipulation using a micro-suction device. Careful manipulation and conservative resection followed by stereotactic radiosurgery may be a valid strategy for managing pituitary adenomas invading the cavernous sinus.