Can a child survive a basilar artery injury during endoscopic third ventriculostomy? case-based review

Endoscopic third ventriculostomy (ETV) has become a cornerstone in the management of obstructive hydrocephalus, offering an alternative to shunt placement. Although considered safe, rare vascular injuries-particularly those involving the basilar artery-can lead to catastrophic complications. These lesions may remain clinically silent initially, resulting in delayed pseudoaneurysm diagnosis.

We report a pediatric case of basilar artery pseudoaneurysm following ETV and tumor biopsy, accompanied by a literature review on the incidence, diagnostic strategies, management, and outcomes of post-ETV major vascular injuries.

Despite intraoperative bleeding that was controlled during surgery and an apparently uneventful early postoperative course, the patient developed a basilar artery pseudoaneurysm, successfully treated with coil embolization. The literature review demonstrates that pseudoaneurysms may form even after an apparently stable postoperative period, reinforcing the need for early vascular imaging when significant intraoperative hemorrhage occurs.

Not every intraoperative hemorrhage mandates immediate vascular imaging; however, profuse, difficult-to-control arterial bleeding requiring prolonged irrigation should always raise suspicion of vascular injury. If the initial angiography is negative, repeat evaluation within 10-15 days is essential, as vasospasm or delayed pseudoaneurysm formation may obscure early findings. Awareness of this risk can prevent catastrophic rebleeding and improve patient outcomes.