Department of Neurosurgery, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and NeuroSciences (NIMHANS), Bangalore, India.
Acta Neurochir Suppl. 2023;130:95-101. doi: 10.1007/978-3-030-12887-6_12.
Endoscopic third ventriculostomy (ETV) is a well-established neurosurgical procedure. However, it carries risks of intraoperative complications, among which major vascular injury is the most dangerous. Reportedly, prominent bleeding during ETV has been noted in <1% of cases. Herein, we describe a case of a 34-year-old woman with occlusive hydrocephalus caused by a quadrigeminal cistern arachnoid cyst, who developed a pseudoaneurysm after injury of the basilar artery apex during ETV. Complete obliteration of the pseudoaneurysm with endovascular balloon-assisted coiling was done on the first postoperative day, and the patient demonstrated gradual recovery, but approximately 4 weeks later, she suffered massive rebleeding, seemingly due to rupture of the weak pseudoaneurysm wall, which resulted in her death. Careful evaluation of sagittal T2-weighted magnetic resonance images before ETV may be invaluable for assessment of the basilar artery position in relation to the third ventricle floor. In addition, use of a blunt surgical instrument (instead of a sharp one or cautery) for fenestration may be safer for prevention of arterial injury. Finally, special care should be applied in cases with an opaque third ventricle floor and inability to visualize the basilar artery during ETV.
内镜第三脑室造瘘术（ETV）是一种成熟的神经外科手术。然而，它存在术中并发症的风险，其中主要的血管损伤是最危险的。据报道，在 <1%的病例中观察到 ETV 期间明显出血。在此，我们描述了一例 34 岁女性因四叠体池蛛网膜囊肿导致闭塞性脑积水，在 ETV 过程中损伤基底动脉顶点后发展为假性动脉瘤。在术后第一天，使用血管内球囊辅助弹簧圈进行了假性动脉瘤的完全闭塞，患者逐渐恢复，但大约 4 周后，她发生了大量再出血，似乎是由于假性动脉瘤壁的薄弱破裂所致，导致其死亡。在 ETV 之前仔细评估矢状 T2 加权磁共振图像对于评估基底动脉与第三脑室底部的关系可能是非常有价值的。此外，使用钝性手术器械（而不是锐器或电灼）进行开窗可能更安全，可预防动脉损伤。最后，对于第三脑室底部不透明且在 ETV 期间无法观察到基底动脉的病例，应特别小心。
