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(description from the article): complications: skull base and cerebrovascular walter c.Jean, md,1,2 fady t.Charbel, md,3 aaron a.Cohen-gadol, md, msc, mba,4 william t.Couldwell, md, phd,5 michael t.Lawton, md,6 michael mcdermott, md,7,8 jacques j.Morcos, md,9 robert f.Spetzler, md,6 and harry r.Van loveren, md2 part 10: chondrosarcoma multiple complications.Objective: the patient was a young woman found to have an expansile lesion of the right petrous bone.Her complaints included migraine headaches with nausea and photophobia, intermittent ringing in the right ear, and right aural fullness with difficulty "popping her ear." she had also had several minor ear infections.Her audiogram was normal.Imaging revealed a mass in her right petrous bone, but the patient was deemed asymptomatic from this lesion.She presented to the neurosurgery department at 2 months postpartum, and her primary desire was to bond with her new baby.The presumptive diagnosis was chondrosarcoma, and surveillance was the recommendation.She remained stable for 2 years, but at the 3-year surveillance mark the tumor had slightly increased in size.Axial images showed a tumor size of 2.6 × 1.8 cm (previously 2.03 × 1.6 cm).The patient declined to undergo resection.She had no clinical symptoms and her neurological condition was stable.Two years later, she experienced double vision, occasional facial numbness, and a sense of fullness in the ear.Examination showed an abducens palsy and she agreed to undergo surgery.Surgical plan an endoscopic endonasal transpterygoid approach was performed, and we encountered a mass that was surprisingly firm for a presumptive chondrosarcoma.Despite the confirmed location by stereotactic guidance, the neuropathology team remained steadfast in their opinion that we were taking biopsies of only dense fibrous tissue and must be outside the mass.The mass was partially resected, and scalpels and rongeur had to be used for its detachment.Because of the proximity of the carotid artery and cranial nerves, a more thorough resection was deemed imprudent.Postoperatively, the patient's abducens palsy resolved but was replaced by hypoglossal paralysis.We recommended radiation therapy based on biological behavior, but the radiation oncology team hesitated given the absence of a confirmed histopathological diagnosis.Two years later, the mass filled the space left by the previous resection.We recommended repeat surgery with the same surgical approach and a broader exposure for the expected firm tumor.A transcranial approach was considered but set aside as the excessive aeration of the petrous bone posed a higher risk of csf leakage.The repeat endoscopic endonasal transpterygoid surgery was progressing despite the expected firm consistency of the recurrent tumor.The only effective tools against the tumor were a scalpel and an aggressive version of the cusa.We nicked the wall of the cavernous sinus with a diamond burr on two occasions, and on the second, there was pulsatile bleeding.Both episodes were stopped with injection of surgiflo (johnson & johnson).Following surgery, the patient woke up with a mild left hemiparesis, and mri revealed evidence of an embolic stroke.The ct angiogram was normal and the patient was discharged to rehabilitation and improved rapidly from her hemiparesis.However, on day 9 she experienced a sudden, severe epistaxis and was rushed back to hospital.Again, the ct angiogram was normal, but a cerebral angiogram revealed a pseudoaneurysm on the inferior cavernous segment of the carotid artery.We opted to proceed with stent coiling.Two days later, repeated diagnostic cerebral angiography revealed that the cavernous segment of the carotid artery was blocked.The right supraclinoid artery was reconstituted through the ophthalmic artery.Additionally, strong collaterals were observed from the left hemisphere to the right hemisphere via the anterior communicating artery, without any venous delay.It is noteworthy that the patient remained asymptomatic throughout the procedure.Discussion: this incredible scenario whereby the patient recovered from the majority of these insults in good condition is a testament to luck rather than knowledge, planning, or execution.The first misstep was delaying surgical intervention even when tumor growth was evident and the patient was still asymptomatic.To be sure, the patient was resistant to surgery, but we allowed this decision to linger for 2 years until she presented with a neurological deficit.It was poor judgment on our part because a more convincing argument for surgery could have been made.The second misstep was poor execution.One surgery should have been enough.We did not complete the resection as was required by the presumptive diagnosis of chondrosarcoma, too easily dissuaded by a frozen-section diagnosis of fibrosis.The biological behavior, symptomatic progression, and navigation confirmation of anatomy all demanded firmer action.The third misstep was poor execution at the second surgery.Nicking the carotid was bad enough; doing it twice was even harder to explain.With pulsatile bleeding from the area of the cavernous sinus, liquid hemostatic agents should not be used, as evidenced by the downstream penetration in this patient and the resultant embolic strokes.The fourth misstep was performing a ct angiography study in the patient after the strokes rather than a cerebral angiography study.This misstep was born out of complication fatigue, the feeling that we have put the patient through so much unnecessary trauma that we need to stop.This resulted in reluctance to pursue another study, an invasive study with further risk, which nonetheless was the proper thing to do.We might have identified the pseudoaneurysm at that time prior to a life-threatening nasal hemorrhage.At a morbidity and mortality conference early in my career i received a backhanded compliment from my mentor, "thank you so much for presenting this complication.Your colleagues seem to keep making the same mistakes over and over again, but you, on the other hand, make new complications that we never even knew were possible." our patient is quite well at this time, and her residual tumor has been treated with proton-beam therapy.Her case has a permanent place in my "cemetery of regrets.".
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