Vasospasm following tumor removal: report of 5 cases

Management of postoperative cerebral vasospasm in skull base surgeries: A systematic review of case reports and series

Background

This study provides a comprehensive overview of the management of postoperative vasospasm after skull base surgeries. This phenomenon is rare but can be of serious sequelae.

Methods

Medline, Embase, and PubMed Central were searched, along with examining the references of the included studies. Only case reports and series that reported vasospasm following a skull base pathology were incorporated. Cases with pathologies other than skull base, subarachnoid hemorrhage, aneurysm, and reversible cerebral vasoconstriction syndrome were excluded from the study. Quantitative data were presented as mean (Standard Deviation) or median (range), accordingly, while qualitative data were presented as frequency (percentage). Chi- square test and one-way analysis of variance were used to assess for any association between the different factors and patient outcomes.

Results

We had a total of 42 cases extracted from the literature. The mean age was 40.1 (±16.1) with approximately equal males and females (19 [45.2%] and 23 [54.8%], respectively). The time to develop vasospasm after the surgery was 7 days (±3.7). Most of the cases were diagnosed by either angiogram or magnetic resonance angiography. Seventeen of the 42 patients had pituitary adenoma as the pathology. Anterior circulation was nearly affected in all patients. For management, most patients received pharmacological with supportive management. Twenty-three patients had an incomplete recovery as a result of vasospasm.

Conclusion

Vasospasm following skull base operations can affect males and females, and most patients in this review were middle-aged adults. The outcome of patients varies; however, most patients did not achieve a full recovery. There was no correlation between any factors and the outcome.

Symptomatic cerebral vasospasm following posterior fossa hemangioblastoma resection: illustrative case

BACKGROUND

Symptomatic cerebral vasospasm following posterior fossa intra-axial tumor resection is a rare phenomenon with only seven cases previously reported in the literature. The condition appears distinct to vasospasm following supratentorial tumor resection and extra-axial tumor resection of the posterior fossa. It shares, however, similarities with vasospasm following aneurysmal subarachnoid hemorrhage.

OBSERVATIONS

The authors describe their experience with a 23-year-old female who developed delayed symptomatic vasospasm following resection of a left parapontine cerebellar hemangioblastoma. Tumor resection was complicated by rupture of a fragile arterialized vein, resulting in significant hemorrhage. The patient developed several episodes of focal and variably reversible neurological deficit. These clinical signs corresponded with angiographically confirmed vasospasm, which responded to standard therapies for vasospasm post aneurysmal subarachnoid hemorrhage.

LESSONS

This case and literature review highlight that symptomatic vasospasm is a rare, potentially highly morbid complication of posterior fossa intra-axial tumor resection. This phenomenon may be related to significant intraoperative or postoperative hemorrhage. Postoperative radiological findings such as high risk modified Fisher scale hemorrhage could alert clinicians to this condition.

Diffuse Cerebral Vasospasm After Removal of a Posterior Fossa Hemangioblastoma in a 62-Year-Old Woman

BACKGROUND

The development of diffuse cerebral vasospasm after the removal of a brain tumor is extremely rare. We report a case of cerebral vasospasm after the removal of a posterior fossa hemangioblastoma.

CASE DESCRIPTION

A 62-year-old woman presented with a 1-month history of vertigo and nausea. Neurologic examination revealed that she was alert, with no paresis, and a mild left-sided cerebellar ataxia. Contrast-enhanced magnetic resonance imaging showed a cystic lesion with a strongly enhancing nodule, measuring 20 × 26 mm in diameter, in the cerebellar dorsal vermis. Angiography revealed that the lesion had feeding arteries from the left posterior inferior cerebellar artery. A diagnosis of hemangioblastoma was suspected and surgery was performed. On the first postoperative day, paresis of the right-sided extremities occurred. Diffusion-weighted imaging showed a high-intensity area in the medial side of the left frontal lobe. Magnetic resonance angiography indicated diffuse cerebrovascular stenosis. Considering these findings to be caused by vasospasm, we started the treatment used for vasospasm secondary to aneurysmal subarachnoid hemorrhage. Magnetic resonance angiography on the 13th postoperative day revealed an improvement in the cerebrovascular stenosis. In this case, it appears that the cause of vasospasm was intraoperative spillage of the contents of the cyst.

CONCLUSIONS

Although the occurrence of diffuse cerebral vasospasm after the removal of brain tumors in the posterior fossa is rare, this complication should be noted as a potential postoperative complication after tumor removal; this should lead to earlier diagnosis and treatment and a potentially better prognosis.

Symptomatic Cerebral Vasospasm After Transsphenoidal Tumor Resection: Two Case Reports and Systematic Literature Review

Cerebral vasospasm is a rare life-threatening complication of transsphenoidal surgery (TSS). We report our experience with two cases of symptomatic vasospasm after endoscopic TSS, alongside a systematic review of published cases. Two patients who underwent endoscopic TSS for resection of a tuberculum sella meningioma (case 1) and pituitary adenoma (case 2) developed symptomatic vasospasm. Clinical variables, including demographics, histopathology, the extent of subarachnoid hemorrhage (SAH), diabetes insipidus (DI), day of vasospasm, vasospasm symptoms, vessels involved, management, and clinical outcome, were retrospectively extracted. We subsequently reviewed published cases of symptomatic post-TSS vasospasm. Including our two cases, we identified 34 reported cases of TSS complicated by symptomatic vasospasm. Female patients accounted for 20 (58.8%) of 34 cases. The average age was 48.1 ± 12.9 years. The majority of patients exhibited postoperative SAH (70.6%). The average delay to vasospasm presentation was 8.5 ± 3.6 days. The majority of patients exhibited vasospasm in multiple vessels, typically involving the anterior circulation. Hemodynamic augmentation with hemodilution, hypertension, and hypervolemia was the most common treatment. Death occurred in six (17.6%) of 34 patients. Common deficits included residual extremity weakness (17.6%), pituitary insufficiency (8.8%), and cognitive deficits (8.8%). Symptomatic vasospasm is a rare, potentially fatal complication of TSS. The most consistent risk factor is SAH. Early diagnosis requires a high index of suspicion when confronted with intractable DI, acute mental status change, or focal deficits in the days after TSS. Morbidity and death are significant risks in patients with this complication.

Predictors of Acute Vertebrobasilar Vasospasm following Tumor Resection in the Foramen Magnum Region

Objective

Cerebral vasospasm can occur after skull base tumor removal. Few studies concentrated on the posterior circulation vasospasm after tumor resection in the posterior fossa. We aimed to identify the risk factors associated with postoperative vertebrobasilar vasospasm after tumor resection in the foramen magnum.

Methods

We retrospectively reviewed the data of 62 patients with tumors in the foramen magnum at our institution from January 2010 to January 2015. The demographic data, tumor features, surgical characteristics were collected. Vertebrobasilar vasospasm was evaluated by bedside transcranial Doppler before surgery and on postoperative day 1, 3, 7. Univariate and multivariate analyses were performed to determine the predictors of postoperative vasospasm in the posterior circulation.

Results

Vertebrobasilar vasospasm was detected in 28 (53.8%) of the 62 patients at a mean time of 3.5 days after surgery. There were 5 (8%) patients with severe vasospasm according to the grading criteria. Age, tumor type, tumor size, vertebral artery encasement, and surgical time were significantly related to vasospasm in the univariate analysis. Further multivariate analysis demonstrated that only age and vertebral artery encasement were independent risk factors predicting the occurrence of postoperative vertebrobasilar vasospasm.

Conclusions

The incidence of acute vertebrobasilar vasospasm is not uncommon after foramen magnum tumor resection. Age and vertebral artery encasement are significantly correlated with postoperative vasospasm. Close monitoring of vasospasm should be given to patients with younger age and the presence of vertebral artery encasement on the preoperative imaging to facilitate early diagnosis and intervention.

Vasospasm Post Pituitary Surgery: Systematic Review and 3 Case Presentations

Background:

Vasospasm is a known complication of aneurysmal subarachnoid hemorrhage and is a major cause of neurological morbidity and mortality. It is infrequently associated with pituitary adenoma surgery. We report three cases and present a systematic review of the literature with a view towards guiding neurosurgeons in the prevention and management of this complication.

Results:

Including our experience, vasospasm complicating pituitary adenoma surgery has been documented in 29 patients (mean age of 45). All cases occurred in the setting of a postoperative hemorrhage: 21 had a subarachnoid hemorrhage and 10 had a postoperative hematoma requiring evacuation. Initial clinical appearance of delayed cerebral ischemia attributable to vasospasm occurred from postoperative Days 2-13 (most commonly Day 5). Digital subtraction angiography and medical management were the most common diagnostic and therapeutic strategies, respectively. Glasgow Outcome Scores were ≤3 in 59% of cases. Univariate logistic regression identified later diagnosis of vasospasm and surgery for hematoma evacuation to be independently associated with better outcomes.

Conclusion:

Vasospasm should be considered in the differential diagnosis of patients demonstrating altered mental or neurological status following pituitary surgery, particularly if there has been postoperative hemorrhage of any degree. Prompt treatment should be instituted to optimize outcome.

Symptomatic cerebral vasospasm following resection of a medulloblastoma in a child

BACKGROUND

Vasospasm may occur following intracranial tumor resection but is uncommon following resection of tumors in the posterior fossa.

METHODS

Case report.

RESULTS

Here, we report an unusual pediatric case of symptomatic cerebral vasospasm following resection of a posterior fossa medulloblastoma in a 10-year-old child. CT angiogram and serial Transcranial Doppler (TCD) studies confirmed the presence of vasospasm and response to hemodynamic augmentation therapy, resulting in favorable outcome.

CONCLUSION

This case illustrates an unusual complication of posterior fossa tumor resection, and the potential utility of TCD studies in the detection and management of vasospasm in pediatric neurocritical care.

Use of Transcranial Doppler (TCD) ultrasound in the Neurocritical Care Unit

Transcranial Doppler (TCD) is a portable device that uses a handheld 2-MHz transducer. It is most commonly used in subarachnoid hemorrhage where cerebral blood flow velocities in major intracranial blood vessels are measured to detect vasospasm in the first 2 to 3 weeks. TCD is used to detect vasospasm in traumatic brain injury and post-tumor resection, measurement of cerebral autoregulation and cerebrovascular reactivity, diagnosis of acute arterial occlusions in stroke, screening for patent foramen ovale and monitoring of emboli. It can be used to detect abnormally high intracranial pressure and for confirmation of total cerebral circulatory arrest in brain death.

Cerebrovasospasm following endoscopic cerebrospinal fluid leak repair

Endoscopic repair of spinal fluid leaks is a commonly performed procedure with low morbidity. However, this is the first report of cerebrovasospasm, following endoscopic repair of a cerebrospinal fluid (CSF) leak. A 51-year-old woman underwent endoscopic repair of a spontaneous CSF leak. She subsequently developed symptomatic cerebrovasospasm on postoperative day 3. This was successfully treated with intraarterial verapamil infusion.

Intracranial vasospasm with delayed ischaemic deficit following epidermoid cyst resection

Intracranial vasospasm following surgical removal of intracranial tumours is rare. To our knowledge there have been no previously reported cases of delayed vasospasm occurring post debulking of epidermoid cysts. We report a case in which vasospasm led to established cerebral infarction 2 weeks postoperatively. MRI and serial magnetic resonance angiography (MRA) reliably show initial multiple stenoses in the vertebral and internal carotid arteries followed by their spontaneous normalisation. MRA imaging is now of sufficient quality to enable it to be a safe and effective means of both looking for vasospasm and monitoring its resolution.

Cerebral vasospasm after resection of an esthesioneuroblastoma: case report and literature review

BACKGROUND

In the last 40 years, there were several reports of symptomatic cerebral vasospasm occurring after resection of brain neoplasms. In most cases, delay in recognition of this complication leads to significant neurologic deterioration postoperatively, regardless of the outcome of surgery. We illustrate in this report a case of cerebral vasospasm after resection of an esthesioneuroblastoma in an adult patient. This is the first report of vasospasm after resection of this neoplasm.

CASE DESCRIPTION

A 41-year-old woman presented with complaints of headache, dizziness, visual blurring, and diplopia of several-day duration. Funduscopic examination revealed papilledema. Radiological studies revealed a large frontal lobe mass extending through the cribriform plate into the ethmoid sinus with accompanying brain edema. The patient underwent a craniotomy for resection of the neoplasm. Pathological findings were consistent with a high-grade esthesioneuroblastoma. Eleven days postoperatively, the patient's neurologic status declined. Diffusion-weighted MRI of the brain showed an infarct involving mainly the left PCA as well as branches of the left anterior and middle cerebral arteries. Angiography revealed narrowing of the corresponding cerebral vessels consistent with vasospasm. Hypervolemic, hypertensive therapy with nimodipine and corticosteroids were instituted. The patient initially improved but was left with a right homonymous hemianopsia upon discharge 23 days postoperatively.

CONCLUSIONS

Delayed neurologic deficit from vasospasm after tumor resection is a complication that is being reported in increasing numbers. These cases involved tumors in or adjacent to the basal cisterns, or surgical approaches that increase the propensity of blood to accumulate intraoperatively or postoperatively in a specific pattern in the basal subarachnoid space. A high index of suspicion for vasospasm should be maintained in patients who develop delayed neurologic deficit, especially when there is evidence of profuse intraoperative bleeding or postoperative blood in the basal cisterns. Early recognition of this phenomenon and early institution of proper therapy can reverse some or all of the neurologic deficit and improve the overall outcome for these patients.

Delayed ischemic optic neuropathy after surgery on skull base meningiomas successfully treated with nimodipine and rheological therapy: report of two cases

Two patients operated on because of skull base meningiomas experienced delayed ischemic optic neuropathy with loss of vision in one eye on days 6 and 12 after surgery. Treatment with nimodipine and rheological therapy was effective in restoring visual acuity. Possible pathophysiological mechanisms and treatment options are discussed.

Postoperative vasospasm of unruptured paraclinoid carotid aneurysms: analysis of 30 cases

This study was conducted to determine the incidence, severity, and causes of delayed vasospasm after clipping of unruptured paraclinoid aneurysms of the internal carotid artery (ICA). A retrospective analysis was made of 30 patients, who underwent clipping of unruptured paraclinoid aneurysms in our institution between 1991 and 1998. We compared angiograms before and after operation and classified them into two groups: vasospasm group and non-vasospasm group. Eleven variables were assessed as to their relationship to delayed vasospasm. There were 9 patients (30%) in the vasospasm group, of which 3 patients (10%) were clinically symptomatic. For all symptomatic patients, aggressive treatment, including triple-H therapy, was conducted with good outcome. The number of clips used (p<0.04) and temporary occlusion of the ICA (p<0.005) were statistically significant factors associated with the incidence of vasospasm. It is suggested that mechanical stimulation to the vascular wall of the ICA is responsible for causing spasm in addition to intraoperative bleeding around the dural ring.