Cerebral Vasospasm after Posterior Fossa Tumor Surgery: A Case Report and Literature Review

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.

Arterial Spin-Labeling Perfusion Metrics in Pediatric Posterior Fossa Tumor Surgery

BACKGROUND AND PURPOSE

Pediatric posterior fossa tumors often present with hydrocephalus; postoperatively, up to 25% of patients develop cerebellar mutism syndrome. Arterial spin-labeling is a noninvasive means of quantifying CBF and bolus arrival time. The aim of this study was to investigate how changes in perfusion metrics in children with posterior fossa tumors are modulated by cerebellar mutism syndrome and hydrocephalus requiring pre-resection CSF diversion.

MATERIALS AND METHODS

Forty-four patients were prospectively scanned at 3 time points (preoperatively, postoperatively, and at 3-month follow-up) with single- and multi-inflow time arterial spin-labeling sequences. Regional analyses of CBF and bolus arrival time were conducted using coregistered anatomic parcellations. ANOVA and multivariable, linear mixed-effects modeling analysis approaches were used. The study was registered at clinicaltrials.gov (NCT03471026).

RESULTS

CBF increased after tumor resection and at follow-up scanning (P = .045). Bolus arrival time decreased after tumor resection and at follow-up scanning (P = .018). Bolus arrival time was prolonged (P = .058) following the midline approach, compared with cerebellar hemispheric surgical approaches to posterior fossa tumors. Multivariable linear mixed-effects modeling showed that regional perfusion changes were more pronounced in the 6 children who presented with symptomatic obstructive hydrocephalus requiring pre-resection CSF diversion, with hydrocephalus lowering the baseline mean CBF by 20.5 (standard error, 6.27) mL/100g/min. Children diagnosed with cerebellar mutism syndrome (8/44, 18.2%) had significantly higher CBF at follow-up imaging than those who were not (P = .040), but no differences in pre- or postoperative perfusion parameters were seen.

CONCLUSIONS

Multi-inflow time arterial spin-labeling shows promise as a noninvasive tool to evaluate cerebral perfusion in the setting of pediatric obstructive hydrocephalus and demonstrates increased CBF following resolution of cerebellar mutism syndrome.

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.