Case Reports & Case Series (CRP) Coincident intrasellar persistent trigeminal artery and craniopharyngioma: case report and implications for transsphenoidal surgery ☆ Justin Seltzer, B.A. a, ⁎ , Shuhan He, B.S. a , Mark S. Shiroishi, M.D. b , Joshua W. Lucas, M.D. a , Darryl H. Hwang, Ph.D. b , Gabriel Zada, M.D. a a Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, CA, United States b Department of Radiology, Keck School of Medicine of USC, Los Angeles, CA, United States abstract article info Article history: Received 14 July 2014 Revised 4 September 2014 Accepted 14 September 2014 Keywords: Transsphenoidal Endoscopic Endonasal Craniopharyngioma Trigeminal artery The persistent trigeminal artery (PTA) is the largest and most commonly occurring type of remnant fetal arteries, typically originating from the posterior bend or lateral wall of the intracavernous carotid artery. There are no published reports of coexisting PTA and midline epithelial tumors. We describe a coincident case of craniopharyngioma associated with an adjacent PTA traversing through the sella turcica, which are both developmental midline skull base anomalies. The caliber and location of the PTA precluded an endoscopic endonasal operation; the tumor was safely resected via a supraorbital keyhole approach. Anatomic implications pertaining to surgical approach and treatment are also discussed. Surgeons performing endonasal skull base operations should be vigilant for the presence of PTAs and related vascular anomalies on MR imaging. Noninvasive vascular imaging can confirm and assist with preoperative planning. © 2014 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Introduction The persistent trigeminal artery (PTA) is the largest and most common type of remnant fetal carotid–basilar anastomotic arteries, seen in 0.1%–1.0% of cerebral angiograms [1,2]. PTAs are known to be associated with a wide range of pathology [3]. In this article, we describe the first known case of craniopharyngioma associated with a PTA. We also review the literature and discuss the impact of anatomic variation on surgical planning. Case report History A 56-year-old man presented with severe visual loss in the right eye and bitemporal hemianopsia. MRI demonstrated a large midline suprasellar mass adherent to vessels of the circle of Willis and compressing the optic chiasm and hypothalamus. Fig. 1 shows a large flow void that was noted directly inferior to the tumor on MRI. Figs. 2 and 3 show a large fetal-type PTA coursing along the left and midline aspects of the sella turcica, exiting via a foramen in the dorsum sellae and connecting the left internal carotid artery to the basilar artery on CT angiogram. The PTA was Saltzman type I, with the left vertebral artery terminating as the PICA and hypoplastic right vertebral and basilar arteries. Operation Due to the caliber and course of the PTA, a right supraorbital keyhole approach was selected for tumor resection. The tumor was internally debulked from the left optic nerve, carotid artery, and optic chiasm. The pituitary stalk, infiltrated with tumor, was sacrificed at the level of the diaphragma sellae. The PTA was seen coursing immediately below the diaphragma sellae and confirmed using micro-Doppler ultrasonography. Tumor dissection between the left P1 artery and the basilar artery was successful; only a small area of residual tumor remained firmly attached to the basilar artery and was deliberately left in place. Pathological findings Pathology confirmed that the suprasellar mass was an adamanti- nomatous craniopharyngioma. Postoperative course As expected based on deliberate resection of the tumor and pituitary stalk, panhypopituitarism with diabetes insipidus requiring full hormone replacement developed postoperatively. Stereotactic Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 1 (2014) 91–93 ☆ The authors have no relevant conflicts of interest or disclosures. ⁎ Corresponding author at: 1200 North State St. Suite 3300 Los Angeles, CA 90033. Tel.: +1 323 226 7421. E-mail address: jseltzer@usc.edu (J. Seltzer). http://dx.doi.org/10.1016/j.inat.2014.09.001 2214-7519/ © 2014 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Contents lists available at ScienceDirect Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com brought to you by CORE View metadata, citation and similar papers at core.ac.uk provided by Elsevier - Publisher Connector