Fatal hemorrhage following trans-sphenoidal resection of a pituitary adenoma: a case report and review of the literature

Kepron, Charis; Cusimano, Michael D.; Pollanen, Michael S.

doi:10.1007/s12024-010-9154-0

Cited by 3 publications

(6 citation statements)

References 13 publications

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“…The sphenopalatine artery exits from the sphenopalatine foramen and supplies the majority of the nasal mucosa; its two major branches are the lateral nasal septal artery and PNSA ( Figures 1A , B ). The PNSA runs along the anteroinferior wall of the sphenoid sinus and is distributed on the posterior portion of the nasal septum ( 24 ). In EETS, PNSA injury usually occurs when the sphenoidal ostium is enlarged in an inferior direction, which is regarded as an important risk factor for epistaxis ( 25 ).…”

Section: Discussionmentioning

confidence: 99%

“…During EETS, extended sphenoidotomies are frequently required for sufficient exposure and total resection of tumors. The PNSA crosses the lower portion of the anterior wall of the sphenoid sinus and is located in the mucosal layer ( 24 ). In our series, all 8 patients had downward extension of the septal mucosal incision, in which 6 had intraoperative bleeding of PNSA that were cauterized by bipolar diathermy.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Incidence, risk factors, management and prevention of severe postoperative epistaxis after endoscopic endonasal transsphenoidal surgery: a single center experience

Liu

Wang

et al. 2023

Front. Surg.

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ObjectivePostoperative epistaxis is a very rare but severe complication after endoscopic endonasal transsphenoidal surgery (EETS) that can lead to catastrophic consequences. However, the incidence, risk factors, management and prevention of postoperative epistaxis remain unclear.Patients and methodsConsecutive patients with pituitary adenoma (PA), Rathke's cleft cyst, craniopharyngioma, or clival chordoma who received EETS in our department between September 2020 and November 2022 were retrospectively analyzed. The incidence, risk factors, management and prevention of postoperative epistaxis were investigated and analyzed.ResultsA total of 557 consecutive patients who received EETS were included in this study. Eight patients (1.4%) (7 PAs and 1 Rathke's cleft cyst) experienced severe postoperative epistaxis. The size of the PAs was 9.6 mm–46.2 mm, with a median size of 22.1 mm. Epistaxis occurred 4 h to 30 days (median 14.5 days) postoperatively. Bleeding was stopped in 3 patients after nasal packing with iodoform gauze. The remaining 5 patients for whom nasal packing was insufficient were all sent to the operating room, and posterior nasal septal artery (PNSA) bleeding was identified and successfully treated with endoscopic bleeding artery electrocauterization under general anesthesia. In the EETS, all 8 patients had downward extension of the septal mucosal incision, in which 6 had intraoperative bleeding of PNSA that were cauterized by bipolar diathermy. Four patients had causative factors, including administration of antiplatelet agents, Valsalva-like manoeuvre, nose blowing and removal of nasal packing, respectively. No patients had recurrent epistaxis during the follow-up period.ConclusionPost-EETS epistaxis is a rare but severe complication that could lead to catastrophic consequences, and one of the most common bleeding sources is the PNSA. Endoscopic bleeding artery electrocauterization under general anesthesia may be a safe, economic and effective measure for epistaxis refractory to nasal packing. Avoiding excessive downward extension of the septal mucosal incision could contribute to the prevention of postoperative epistaxis.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Incidence, risk factors, management and prevention of severe postoperative epistaxis after endoscopic endonasal transsphenoidal surgery: a single center experience

Liu

Wang

et al. 2023

Front. Surg.

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“…Measurement of the sinus cavity can help predict the safety of the operation. Bony defects of the sphenoid posterior wall are occasionally found in patients with excess pneumatization in the sella of the saddle pillow type, which results in internal carotid artery exposure, with a prevalence of 10% [ 22 ]; this is a serious complication in pituitary adenoma resection [ 23 ]. In the present study, the prevalence was 3.7%.…”

Section: Discussionmentioning

confidence: 99%

Preoperative Computed Tomography (CT) Evaluation of Anatomical Abnormalities in Endonasal Transsphenoidal Approach in Pituitary Adenoma

et al. 2018

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BackgroundThis study aimed to retrospectively analyze patient clinical data to investigate the effects of computed tomography (CT) reconstruction and the measurement of abnormal structures in the endonasal sphenoidal sinus approach on the operative effects in patients undergoing pituitary adenoma resection.Material/MethodsThe records of 53 patients who underwent pituitary adenoma resection via the endonasal transsphenoidal approach in the Neurosurgery Department of Tai’an City Central Hospital from December 2010 to June 2016 were analyzed retrospectively. All cases showed anatomical abnormalities in the endonasal transsphenoidal approach that were detected by conventional CT scans. The clinical data of the patients were reviewed. After review, 26 patients who underwent preoperative CT reconstruction and measurement of abnormal structures before surgery were included in the observation group (CT reconstruction group), and 27 patients who did not undergo CT reconstruction and measurement of abnormal structures were included in the control group. Data on intraoperative blood loss, surgical time, hospital stay, and postoperative complications were collected to assess the quality of the surgery.ResultsCompared with the control group, the observation group showed less blood loss (p<0.001), a shorter operation time (p<0.001), fewer postoperative complications (p<0.001), and a shorter hospital stay (p<0.001).ConclusionsPreoperative CT reconstruction and measurement of abnormal structures in patients undergoing pituitary adenoma resection by the endonasal transsphenoidal approach can improve operative quality and reduce complications.

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“…Lethal iatrogenic epistaxis has occurred from procedures such as nasogastric tube insertion , and fatal epistaxis may occur following surgery for conditions such as juvenile nasopharyngeal angiofibroma or after trans‐sphenoidal resection of a pituitary adenoma. The latter was associated with secondary bacterial arteritis of the internal carotid artery . Endoscopic base of skull surgery for entities such as pituitary adenomas, sinonasal malignancies, meningiomas, Rathke cleft cysts, clival chordomas, and craniopharyngiomas has met with great success but here is a 3% risk of postoperative epistaxis.…”

Section: Specific Entities Associated With Epistaxismentioning

confidence: 99%

“…In one report on litigation related to epistaxis, death had occurred in 31% of the cases, related to either the complications of treatment for nasal bleeding, such as aspiration of nasal packing, or to nasal bleeding resulting from another procedure, such as nasogastric tube insertion . Postsurgical epistaxis may be severe . Other medicolegal issues that have involved litigation include delays in diagnosis of underlying malignancy that was responsible for recurrent epistaxis, delays in diagnosis of an impacted foreign body that resulted in septal perforation, and lack of appreciation of anatomical variations in the arterial blood supply to the nose.…”

Section: Medicolegal Issuesmentioning

confidence: 99%

Lethal Epistaxis

Byard

2016

Journal of Forensic Sciences

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Epistaxis or nosebleed refers to bleeding from the nostrils, nasal cavity, or nasopharynx. Occasional cases may present with torrential lethal hemorrhage. Three cases are reported to demonstrate particular features: Case 1: A 51-year-old woman with lethal epistaxis with no obvious bleeding source; Case 2: A 77-year-old man with treated nasopharyngeal carcinoma who died from epistaxis arising from a markedly neovascularized tumor bed; Case 3: A 2-year-old boy with hemophilia B who died from epistaxis with airway obstruction in addition to gastrointestinal bleeding. Epistaxis may be associated with trauma, tumors, vascular malformations, bleeding diatheses, infections, pregnancy, endometriosis, and a variety of different drugs. Careful dissection of the nasal cavity is required to locate the site of hemorrhage and to identify any predisposing conditions. This may be guided by postmortem computerized tomographic angiography (PCTA). Despite careful dissection, however, a source of bleeding may never be identified.

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Fatal hemorrhage following trans-sphenoidal resection of a pituitary adenoma: a case report and review of the literature

Cited by 3 publications

References 13 publications

Incidence, risk factors, management and prevention of severe postoperative epistaxis after endoscopic endonasal transsphenoidal surgery: a single center experience

Incidence, risk factors, management and prevention of severe postoperative epistaxis after endoscopic endonasal transsphenoidal surgery: a single center experience

Preoperative Computed Tomography (CT) Evaluation of Anatomical Abnormalities in Endonasal Transsphenoidal Approach in Pituitary Adenoma

Lethal Epistaxis

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