title: Delayed Carotid Pseudoaneurysms from Iatrogenic Clival Meningeal Branches Avulsion: Recognition and Proposed Management.
abstract: BACKGROUND
  Carotid injury during anterior skull base approaches is promptly recognizable and mandates immediate treatment; likewise, development of pseudoaneurysms after such injuries is anticipated and managed.
  
  
  METHODS
  We report here on the delayed development of a pseudoaneurysm as the result of avulsion of clival meningeal arteries that manifests as unalarming intraoperative bleeding.
  
  
  CONCLUSIONS
  The bleeding is brisk and arterial but easily controlled. Immediate postoperative angiography is negative, necessitating repeated angiography to depict the delayed formation. It is best treated by endovascular means that maintains patency of the carotid artery, calling for the development of a suitable device that obliterates the opening of the pseudoaneurysm while maintaining carotid flow that is deployable in the tortuous carotid artery.
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA. Electronic address: rami.almefty@bnaneuro.net.
authors.forename: Rami
authors.initials: R
authors.lastname: Almefty
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Ian F
authors.initials: IF
authors.lastname: Dunn
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Muhammad Ali
authors.initials: MA
authors.lastname: Aziz-Sultan
authors.affiliation: Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Ossama
authors.initials: O
authors.lastname: Al-Mefty
mesh_terms: D000368:Aged; D017541:Aneurysm, False / Q000000981:diagnostic imaging* / Q000628:therapy*; D015901:Angiography, Digital Subtraction; D020212:Carotid Artery Injuries / Q000000981:diagnostic imaging* / Q000628:therapy*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging*; D002533:Cerebral Angiography; D002817:Chordoma / Q000601:surgery; D000072226:Computed Tomography Angiography; D003388:Cranial Fossa, Posterior / Q000601:surgery; D057210:Delayed Diagnosis; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D018810:Magnetic Resonance Angiography; D008297:Male; D008576:Meningeal Arteries / Q000000981:diagnostic imaging / Q000293:injuries; D008577:Meningeal Neoplasms / Q000601:surgery; D008579:Meningioma / Q000601:surgery; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging* / Q000628:therapy*; D015607:Stents
keywords: Carotid injury; Carotid occlusion; Clivus; Covered stent; Dural artery; Pseudoaneurysm; Skull base; Transsphenoidal