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Aihara S, Umegaki T, Soeda T, Iwamura H, Takeda J, Nonaka M, Kamibayashi T. Cerebral vasospasm occurring immediately after endoscopic transsphenoidal resection of a pituitary adenoma: A case report. Surg Neurol Int 2024; 15:201. [PMID: 38974551 PMCID: PMC11225524 DOI: 10.25259/sni_342_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/23/2024] [Indexed: 07/09/2024] Open
Abstract
Background Cerebral vasospasm is a rare postoperative complication of transsphenoidal pituitary adenoma surgery with potentially severe consequences. These vasospasms generally have a delayed presentation at a mean of 8 postoperative days. We report an unusual case of hyperacute onset of cerebral vasospasm that occurred immediately after surgery. Case Description A 38-year-old man underwent endoscopic transsphenoidal surgery for a nonfunctioning pituitary adenoma. The patient experienced mild subarachnoid hematoma during surgery. Three hours after surgery, he developed rightward conjugate eye deviation and complete paralysis of the left upper and lower extremities. Diagnostic imaging revealed cerebral vasospasm in both middle cerebral arteries, and symptoms improved after intra-arterial administration of fasudil hydrochloride. Conclusion There is a need for prompt diagnosis and therapeutic intervention when typical symptoms of cerebral vasospasm, such as paralysis, occur at any time during the postoperative course.
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Affiliation(s)
- Satoshi Aihara
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Takehiro Soeda
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | | | - Junichi Takeda
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
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Hashikata H, Takebe N, Yoshizaki W, Maki Y. Postoperative vasospasm and cerebral infarction in a patient with large pituitary adenoma and cerebral superficial siderosis. Surg Neurol Int 2023; 14:256. [PMID: 37560577 PMCID: PMC10408626 DOI: 10.25259/sni_397_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/08/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Cerebral vasospasm and infarction are rare complications of transsphenoidal surgery for pituitary adenoma. Cerebral superficial siderosis may result from subarachnoid hemorrhage from a pituitary adenoma. The constellation of cerebral superficial siderosis, cerebral vasospasm, and pituitary adenoma is rare. We describe an extremely rare clinical constellation of immediately postoperative cerebral vasospasm and consequent cerebral infarction in a case with a large pituitary adenoma and cerebral superficial siderosis. CASE DESCRIPTION A 70-year-old man presented with a pituitary adenoma causing a worsening headache. Preoperative magnetic resonance (MR) images revealed cerebral superficial siderosis, suggesting subarachnoid hemorrhage from pituitary apoplexy. MR angiography (MRA) showed no vasospasm. During the transsphenoidal surgery, an intratumoral hematoma was found. The arachnoid membrane was partially torn and intratumoral hematoma entered the subarachnoid space. Intraoperatively, the intracranial vessels remained intact. The suprasellar tumor was almost entirely resected; however, the patient remained comatose postoperatively. Computed tomography revealed ischemic lesions in the bilateral insular and frontotemporal cortex. MRA revealed cerebral vasospasm in the bilateral middle cerebral arteries. The patient was treated with levetiracetam for nonconvulsive status epilepticus and underwent a lumbar peritoneal shunt surgery for secondary hydrocephalus. However, the patient remained listless. CONCLUSION Postoperative cerebral vasospasm and infarction are severe but rare complications for a pituitary adenoma after transsphenoidal surgery. Preoperative and intraoperative subarachnoid hemorrhage might have been a risk factor in our case. Similar cases should be warranted to analyze whether cerebral superficial siderosis may also indicate the risk of severe postoperative vasospasm immediately after transsphenoidal surgery for pituitary adenoma.
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Affiliation(s)
- Hirokuni Hashikata
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Noriyoshi Takebe
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Wataru Yoshizaki
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, Osaka, Japan
| | - Yoshinori Maki
- Department of Neurosurgery, Hikone Chuo Hospital, Hikone, Japan
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Hamzah A, Alharbi AS, Abdulhamid AS, Turkistani AN, Aref MH. Management of postoperative cerebral vasospasm in skull base surgeries: A systematic review of case reports and series. Surg Neurol Int 2023; 14:214. [PMID: 37404488 PMCID: PMC10316141 DOI: 10.25259/sni_441_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/03/2023] [Indexed: 07/06/2023] Open
Abstract
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.
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Affiliation(s)
- Abdulaziz Hamzah
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdullah S. Alharbi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed S. Abdulhamid
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Alaa Nabil Turkistani
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Mohmmed Hani Aref
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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Elias PCL, Volpon M, Azevedo GDG, Machado H, Gonçalves GHM, Carlos Santos A, Mermejo LM, de Castro M, Moreira AC. Cerebral vasospasm following subarachnoid hemorrhage: a rare complication after transsphenoidal surgery for pituitary macroadenoma. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0334. [PMID: 36625275 PMCID: PMC9874954 DOI: 10.1530/edm-22-0334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Summary Postoperative (PO) complications after transsphenoidal surgery (TSS) are rare when performed in pituitary referral centers. Partial hypopituitarism is more frequent and somewhat expected. Meningitis, cerebrospinal fluid leaks, and visual deficits are unusual. Cerebrovascular complications, including cerebral vasospasm are rare, usually under-appreciated and not mentioned to the patient prior to the surgery. This is a report of a 51-year-old male with a non-functioning pituitary macroadenoma presenting with partial hypopituitarism and visual field loss. The patient was submitted to an uneventful TSS. On the first PO day, he developed a left palpebral ptosis with unequal pupils and impaired consciousness (12 points on Glasgow Coma Scale). CT scan revealed a perimesencephalic subarachnoid hemorrhage (SAH) grade 1 according to the modified Fisher scale. High-dose dexamethasone (16 mg/day) was initiated and the patient became more alert (Glasgow 14). On the fifth PO day, due to progression of the neurological deficits (left III, IV, and VI cranial nerves palsy, ataxia, dysdiadochokinesia, right dysmetria, and dysarthria), a magnetic resonance angiography was obtained and revealed a recent mesencephalic infarct without evident vasospasm. Nevertheless, nimodipine 60 mg 4/4 h was initiated. No improvement was seen after 3 days of treatment. The patient was discharged and put on rehabilitation, returning to normal gait and balance after 7 months. This, therefore, is a case of an unexpected mesencephalic infarct probably due to vasospasm induced by minor SAH. Although exceptionally rare, informing the patient about this event prior to TSS is important due to its significant neurological impact. More data are needed considering preventive treatment with nimodipine as soon as SAH is detected after TSS and whether it would improve neurological outcomes. Learning points Whenever neurological deficits arise after transsphenoidal surgery (TSS), systemic infection, meningitis, electrolyte imbalance, and evident hemorrhage must be promptly investigated. Although rare, cerebral vasospasm (CVS) after TSS is associated with high morbidity and high mortality rates. Vigilance for vasospasm is necessary for patients undergoing TSS for pituitary adenoma, especially those with significant suprasellar extension. Informing this event to the patient prior to TSS is essential due to its significant morbidity and mortality. Post-TSS subarachnoid hemorrhage and hemiparesis may be important clues indicating CVS and infarction. There is limited evidence in the literature regarding post-TSS CVS surveillance and treatment strategies which could have an impact on clinical decisions.
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Affiliation(s)
- Paula Condé Lamparelli Elias
- Department of Internal Medicine, Division of Endocrinology, Ribeirão Preto Medical School, University of São Paulo
| | - Marcelo Volpon
- Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo
| | - Giovana de Gobbi Azevedo
- Department of Internal Medicine, Division of Endocrinology, Ribeirão Preto Medical School, University of São Paulo
| | - Helio Machado
- Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo
| | | | - Antonio Carlos Santos
- Department of Radiology, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo
| | - Livia M Mermejo
- Department of Internal Medicine, Division of Endocrinology, Ribeirão Preto Medical School, University of São Paulo
| | - Margaret de Castro
- Department of Internal Medicine, Division of Endocrinology, Ribeirão Preto Medical School, University of São Paulo
| | - Ayrton C Moreira
- Department of Internal Medicine, Division of Endocrinology, Ribeirão Preto Medical School, University of São Paulo
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Ogawa Y, Sato K, Endo T, Tominaga T. Quantification of Tumor Blush of Highly Vascularized Tumors with Slow Feeding System: Representative Use for Giant Pituitary Adenomas. J Neurol Surg A Cent Eur Neurosurg 2021; 83:110-117. [PMID: 34897617 DOI: 10.1055/s-0040-1721014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Modern imaging techniques can identify adverse factors for tumor removal such as cavernous sinus invasion before surgery, but surgeries for giant pituitary adenomas often reveal discrepancies between preoperative imaging and intraoperative findings because pituitary adenomas have feeding arteries with narrow diameters. Current imaging methods are not suitable for tumors with not only large vascular beds but also slow arterial filling. PATIENTS AND METHODS This prospective study recruited 13 male subjects and 9 female subjects with giant pituitary adenomas between November 2011 and 2018. All the patients were investigated with three-dimensional magnetic resonance (MR) imaging, bone image computerized tomography (CT), and digital subtraction angiography (DSA) using a C-arm cone-beam CT scanner with a flat-panel detector and 50% diluted contrast medium. Fine angioarchitecture was evaluated and the tumor blush was quantified using newly developed region of interest (ROI) analysis to establish surgical strategies. RESULTS Seven patients demonstrated no or very faint tumor blushes. In these patients, feeding arteries run centripetally from the surface of the tumor. Fifteen patients showed significant tumor blushes, and the feeding arteries penetrated centrifugally from the inferoposterior pole to the upper pole of the tumor. All the patients were treated according to the angiographic information with successful hemostasis. The patients showed improvement and/or disappearance of the neurologic deficits. The faint and significant blush groups showed significant differences in intraoperative bleeding (p < 0.01) and operation time (p < 0.05). CONCLUSION Specialized evaluation focused on vascularization is required for successful therapy of giant pituitary adenomas.
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Affiliation(s)
- Yoshikazu Ogawa
- Department of Neurosurgery, Kohnan Hospital, Taihaku-ku, Sendai, Japan
| | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Taihaku-ku, Sendai, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Tohoku University, Aoba, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, Aoba, Sendai, Japan
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Budnick HC, Tomlinson S, Savage J, Cohen-Gadol A. Symptomatic Cerebral Vasospasm After Transsphenoidal Tumor Resection: Two Case Reports and Systematic Literature Review. Cureus 2020; 12:e8171. [PMID: 32566415 PMCID: PMC7299537 DOI: 10.7759/cureus.8171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Samuel Tomlinson
- Neurological Surgery, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, USA
| | - Jesse Savage
- Neurological Surgery, Indiana University, Indianapolis, USA
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7
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Suero Molina E, Di Somma A, Stummer W, Briganti F, Cavallo LM. Clinical Vasospasm After an Extended Endoscopic Endonasal Approach for Recurrent Pituitary Adenoma: Illustrative Case and Systematic Review of the Literature. World Neurosurg 2019; 128:29-36. [DOI: 10.1016/j.wneu.2019.04.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/15/2022]
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8
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Mikhaylov NI, Kalinin PL, Savin IA. [Complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 82:105-113. [PMID: 30721224 DOI: 10.17116/neiro201882061105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of endoscopic technique has significantly extended the indications for surgery using the transsphenoidal approach. Currently, more than 90% of pituitary adenomas are operated on transsphenoidally. Transnasal removal of giant pituitary adenomas has become possible. Transition to the endoscopic endonasal approach in removal of pituitary adenomas changed the rate and structure of postoperative complications. We analyzed potential complications after endoscopic endonasal transsphenoidal removal of pituitary adenomas. These include complications of the approach itself (nasal bleeding, perforation of the nasal septum, impaired olfactory function, atrophic rhinitis, synechiae, mucoperiosteal flap necrosis, and external nasal deformities), infectious complications (meningitis, intracranial abscesses), cerebral circulation disorder (subarachnoid hemorrhage, cerebral vasospasm, injury to large vessels, intracranial hematomas), neuro-ophthalmological complications (visual and oculomotor disorders), endocrine (hypopituitarism, diabetes insipidus, hyponatremia) and somatic complications, and nasal liquorrhea. In conclusion, it should be noted that despite continuous improvement of the technique for endoscopic endonasal removal of pituitary adenomas, there is a risk of serious complications, which necessitates the development of techniques for prevention of these complications.
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Affiliation(s)
| | - P L Kalinin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I A Savin
- Burdenko Neurosurgical Institute, Moscow, Russia
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9
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Shao B, Banu MA, Carroll JJ, Meyers PM, Lavine SD, Feldstein NA, Anderson RCE. Cerebral Vasospasm after Open Fenestration of an Arachnoid Cyst in a 4-Year-Old Boy: Case Report and Review of the Literature. Pediatr Neurosurg 2019; 54:132-138. [PMID: 30650412 DOI: 10.1159/000495834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 11/23/2018] [Indexed: 11/19/2022]
Abstract
Cerebral vasospasm is associated with significant morbidity, and most commonly occurs following subarachnoid hemorrhage. Rarely, vasospasm can follow tumor resection and traumatic brain injury. We present the first reported case of a young child who developed diffuse vasospasm following open fenestration of an arachnoid cyst and was promptly treated, with full recovery of neurologic function. Although vasopasm after arachnoid cyst fenestration is rare, it can be included in the differential for a new focal neurologic deficit.
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Affiliation(s)
- Belinda Shao
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Matei A Banu
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Jason J Carroll
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Philip M Meyers
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Sean D Lavine
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Neil A Feldstein
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA.,Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA
| | - Richard C E Anderson
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA, .,Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA,
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Osterhage K, Czorlich P, Burkhardt TR, Rotermund R, Grzyska U, Flitsch J. Symptomatic Vasospasms as a Life-Threatening Complication After Transsphenoidal Surgery. World Neurosurg 2017; 110:180-188. [PMID: 29045853 DOI: 10.1016/j.wneu.2017.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 10/03/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify symptomatic vasospasms as a rare complication after transsphenoidal surgery, with emphasis on management and outcomes. METHODS In this retrospective study, the medical records of 1997 patients who underwent microscopic transsphenoidal surgery at our hospital between 2008 and 2016 were analyzed regarding postoperative vasospasm events, clinical management, and neurologic outcomes. RESULTS Four patients (0.2%) were identified who developed neurologic deficits in the postoperative phase caused by proven vasospasms due to subarachnoid hemorrhage (SAH). All 4 patients were treated according to current state-of-the-art recommendations for SAH-triggered vasospasms and, as ultima ratio, intra-arterial spasmolysis. Nonetheless, all patients developed multilocular ischemic infarctions. Three patients recovered with no or only slight neurologic deficits (2 with a Glasgow Outcome Score [GOS] of 5; 1 with a GOS of 4), and 1 patient died, at 24 days after surgery. CONCLUSIONS Although a rare complication, vasospasms after transsphenoidal surgery can lead to severe and multilocular ischemic infarctions with a wide variety of neurologic impairments. This rare complication should be considered in patients with unexpected postoperative neurologic deficits. Computed tomography (CT)/magnetic resonance imaging and (contrast-enhanced) CT/magnetic resonance angiography are appropriate diagnostic tools. Treatment of vasospasms, including the option of intra-arterial spasmolysis, should not be delayed.
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Affiliation(s)
- Katharina Osterhage
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till R Burkhardt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Grzyska
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Cerebral vasospasm after transsphenoidal surgery for pituitary adenoma: Case report and review of the literature. Neurochirurgie 2017; 63:25-27. [PMID: 28284449 DOI: 10.1016/j.neuchi.2016.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 11/21/2016] [Accepted: 12/02/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Cerebral vasospasm (CVS) is a rare complication of transsphenoidal surgery for pituitary adenomas. CASE REPORT The authors describe a symptomatic cerebral ischemia due to an internal carotid, left middle cerebral artery and anterior cerebral artery vasospasm in a patient undergoing transsphenoidal surgery for a pituitary macro adenoma. The patient was successfully treated by an endovascular balloon angioplasty. CONCLUSION This issue should be taken into account, even when rare, in every patient who has surgery for a pituitary tumor, particularly when it concerns a large macro adenoma with suprasellar extension. Special precautions must be taken to avoid this rare complication.
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12
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Bhogal P, Paraskevopoulos D, Makalanda HL. The use of a stent-retriever to cause mechanical dilatation of a vasospasm secondary to iatrogenic subarachnoid haemorrhage. Interv Neuroradiol 2017; 23:330-335. [PMID: 28604190 DOI: 10.1177/1591019917694838] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To report the use of a stent-retriever in the management of vasospasm secondary to craniopharyngioma resection. Postoperative improvement was seen both clinically and on perfusion imaging. Methods A patient was admitted for resection of a large craniopharygioma. On day 6 postoperatively the patient had an acute hemiparesis. A computed tomography angiogram and perfusion scan demonstrated acute right-sided cerebral vasospasm and a perfusion defect in the territory of the middle cerebral artery (MCA). Results A pREset 4 × 20 mm stent-retriever was used to dilate the M1 and proximal M2 segments of the right MCA mechanically. This resulted in immediate dilatation of the spastic segment and improvement in the transit time on the angiogram. There was an improvement in the clinical status post-procedure and a computed tomography perfusion performed 24 hours after the procedure showed symmetrical perfusion. A computed tomography angiogram and magnetic resonance imaging performed 1 week later showed a symmetrical appearance to the MCA and no evidence of restricted diffusion. Conclusion The use of commercially available stent-retrievers can cause mechanical dilatation of vasospastic vessels. The stents do not need to be deployed for a prolonged period nor do they need to be implanted to have a prolonged dilatory effect on the spastic vessels.
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Affiliation(s)
| | - Dimitris Paraskevopoulos
- 2 Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK.,3 Centre for Neuroscience and Trauma at the Blizard Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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13
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Ogawa Y, Sato K, Matsumoto Y, Tominaga T. Evaluation of Fine Feeding System and Angioarchitecture of Giant Pituitary Adenoma—Implications for Establishment of Surgical Strategy. World Neurosurg 2016; 85:244-51. [DOI: 10.1016/j.wneu.2015.09.087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/25/2015] [Accepted: 09/25/2015] [Indexed: 11/17/2022]
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14
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Abstract
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.
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Popugaev KA, Savin IA, Oshorov AV, Kurdumova NV, Ershova ON, Lubnin AU, Kadashev BA, Kalinin PL, Kutin MA, Killeen T, Cesnulis E, Melieste R. Postsurgical meningitis complicated by severe refractory intracranial hypertension with limited treatment options: the role of mild therapeutic hypothermia. J Neurol Surg Rep 2014; 75:e224-9. [PMID: 25485219 PMCID: PMC4242895 DOI: 10.1055/s-0034-1387188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/03/2014] [Indexed: 12/19/2022] Open
Abstract
Intracranial hypertension is a commonly encountered neurocritical care problem. If first-tier therapy is ineffective, second-tier therapy must be initiated. In many cases, the full arsenal of established treatment options is available. However, situations occasionally arise in which only a narrow range of options is available to neurointensivists. We present a rare clinical scenario in which therapeutic hypothermia was the only available method for controlling intracranial pressure and that demonstrates the efficacy and safety of the Thermogard (Zoll, Chelmsford, Massachusetts, United States) cooling system in creating and maintaining a prolonged hypothermic state. The lifesaving effect of hypothermia was overshadowed by the unfavorable neurologic outcome observed (minimally conscious state on intensive care unit discharge). These results add further evidence to support the role of therapeutic hypothermia in managing intracranial pressure and provide motivation for finding new strategies in combination with hypothermia to improve neurologic outcomes.
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Affiliation(s)
- Konstantin A. Popugaev
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Ivan A. Savin
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Andrew V. Oshorov
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Natalia V. Kurdumova
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Olga N. Ershova
- Neurocritical Care Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Andrew U. Lubnin
- Department of Neuroanesthesia, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Boris A. Kadashev
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Pavel L. Kalinin
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Maxim A. Kutin
- 8th Neurosurgical Department, Burdenko Neurosurgical Research Institute, Russian Academy of Medical Sciences, Moscow, Russian Federation
| | - Tim Killeen
- Department of Neurosurgery, Klinik Hirslanden, Zürich, Switzerland
| | - Evaldas Cesnulis
- Department of Neurosurgery, Klinik Hirslanden, Zürich, Switzerland
| | - Ronald Melieste
- Temperature Management Division Europe, Zoll Medical Corporation, Chelmsford, Massachusetts, United States
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Chong MY, Quak SM, Chong CT. Cerebral ischaemia in pituitary disorders--more common than previously thought: two case reports and literature review. Pituitary 2014; 17:171-9. [PMID: 23612931 DOI: 10.1007/s11102-013-0485-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vasospasm and consequent cerebral ischaemia in aneurysmal subarachnoid haemorrhage are well-described. The development of cerebral ischaemia following pituitary tumour surgery is under-appreciated, and can be attributed to mainly cerebral vasospasm or internal carotid artery compression. We report on two patients with pituitary tumours who developed delayed cerebral ischaemia after transsphenoidal and transcranial pituitary macroadenoma decompression. The patients had vasospasm of intracranial vessels demonstrable on magnetic resonance angiogram. One recovered neurologically following nimodipine and hypertensive-hypervolaemia therapy while the other developed fulminant cerebral infarction. We discuss the complex multi-factorial mechanisms of cerebral ischaemia in pituitary disorders, as well as the management strategies and their limitations.
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Affiliation(s)
- Margaret Yanfong Chong
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
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Kim EH, Oh MC, Kim SH. Angiographically documented cerebral vasospasm following transsphenoidal surgery for pituitary tumors. Pituitary 2013; 16:260-9. [PMID: 22843020 DOI: 10.1007/s11102-012-0415-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Symptomatic cerebral vasospasm (CVS) after transsphenoidal surgery (TSS) is very rare compared with vasospasm resulting from aneurysmal subarachnoid hemorrhage (SAH). Fewer than six cases documented by cerebral angiography have been reported. We evaluated the records of 15 patients in whom SAH developed after TSS. Their clinical symptoms, radiological and laboratory findings were analyzed. Among 15 patients with postoperative SAH, 11 did not show CVS during their postoperative course. However, four patients presented with various clinical symptoms suggestive of CVS on postoperative days 7-9. They showed an abrupt drop of serum sodium level 1 or 2 days before the onset of CVS symptoms. Patients with TSS-related SAH should be managed with proactive and aggressive treatment. Hyponatremia, which usually occurs around the first week after TSS, should not be ignored as a matter of metabolic or hormonal disequilibrium commonly encountered after pituitary surgery.
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Affiliation(s)
- Eui Hyun Kim
- Department of Neurosurgery, Pituitary Tumor Clinic, Yonsei Endocrine Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
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