Cerebral vasospasm following subarachnoid hemorrhage: a rare complication after transsphenoidal surgery for pituitary macroadenoma

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.

Unilateral caudate infarct following pituitary adenoma resection

“…4)10) Some characteristics of the tumor such as size, supra or retrosellar extension, as well as the presence of pituitary apoplexy, have also been associated with vascular postoperative complications. 7) In the reported case, the patient presented a selective infarction of the head of the left caudate nucleus, which topographically corresponds to the territory irrigated by the recurrent artery of Heubner (the largest perforating branch from the proximal anterior cerebral artery [ACA]; its origin is near the A1-ACom-A2 junction of the ACA, arising from the proximal A2 in 90% of cases, and from the distal A1 in 10% of cases). 6) Caudate nucleus is important in the modulation of motor actions and influences associative and cognitive processes.…”

“…They may occur after transsphenoidal or transcranial excision of the pituitary lesion via different mechanisms: (1) direct trauma to the vessel wall, (2) mechanical compression of the vessels, (3) vasospasm secondary to SAH or tumor secretion of vasoactive agents, or (4) hypothalamic injury [ 4 , 10 ]. Some characteristics of the tumor such as size, supra or retrosellar extension, as well as the presence of pituitary apoplexy, have also been associated with vascular postoperative complications [ 7 ].…”