Artery of Percheron and Endoscopic Endonasal Surgery: Case Report and Review of the Literature

Artery of Percheron (AOP) is a rare anatomical variant in which a single perforating artery arising from the P1 segment of the posterior cerebral artery supplies paramedian thalami and rostral midbrain. The occlusion of AOP produces bilateral thalamic ischemia and may be a rare complication in relation to an extended endoscopic endonasal approach. We report the case of a patient who developed AOP damage during endoscopic endonasal surgery (EES); to our knowledge, this complication has been previously reported only in one case, in relation to a second surgery. We also review the anatomical variants in thalamic vascularization and the factors that may be involved in this complication. A 52-year-old female underwent an extended endoscopic endonasal approach with intraoperative neurophysiological monitoring. In the postoperative period, she presented with a decreased level of consciousness and bilateral mydriasis. Magnetic resonance imaging showed rostral midbrain and paramedian thalami ischemia congruent with AOP infarction. AOP infarction may be associated with extended EES when treating lesions with retrosellar extension. Every effort should be made to preserve the small perforating arteries. Intraoperative neurophysiological monitoring of the motor and sensory pathways may not detect damage to the AOP.