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

Budnick, Hailey C.; Tomlinson, Samuel B.; Savage, Jesse J.; Cohen-Gadol, Aaron

doi:10.7759/cureus.8171

Cited by 10 publications

(32 citation statements)

References 39 publications

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“…Budnick et al reviewed the 34 cases of all-cause post-TSS vasospasm, including pituitary adenoma. They reported that SAH proceeded with the onset of symptomatic vasospasm in a large proportion (70.6%) of their patients [23]. Even though our patient did not suffer complications following surgery, including SAH or CSF leakage, our literature review found that 85.2% of those pituitary adenoma patients who experienced vasospasm post-TSS had SAH.…”

Section: Discussionmentioning

confidence: 51%

“…Besides our patients, we also identified 27 cases of pituitary adenoma and 17 publications [6,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] related to this condi- tion. To the best of our knowledge, this is the first patient under 18 years old in our literature review who also has undergone a thrombectomy in her admission after uncomplicated TSS.…”

Section: Discussionmentioning

confidence: 99%

“…The location and vascular encasement are the leading players in terms of preoperative factors. Previous cases emerged that tumors located in the sella region with suprasellar extension are likely to develop vasospasm [6,[21][22][23][24][25]. Adjacency to Willis' circle, particularly in vessel encasement or displacement, makes this location vulnerable.…”

Section: Discussionmentioning

confidence: 99%

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Symptomatic Cerebral Vasospasm After Transsphenoidal Adenoma Resection of the Pituitary

et al. 2022

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Delayed cerebral ischemia (DCI) or vasospasm following transsphenoidal surgery (TSS) is a life-threatening and life-altering event that could potentially cause devastating complications, neurological morbidity, and high mortality. Herein, we report the case of a 16-year-old woman without a marked medical history and unusual complications after TSS for pituitary adenoma resection who developed cerebral vasospasm and infarction after TSS. To the best of our knowledge, this is the first case involving a patient under 18 years old and requiring thrombectomy after TSS. Additionally, we present our review of published case reports to underline the most often presentation characteristics, the interval between TSS and vasospasm, and therapeutic management. With respect to our case, we analyzed 27 cases of TSS complicated by symptomatic vasospasm. We include only pituitary adenoma resection and exclude other causes. The mean age was 47.33 ± 15.22 years at the time of surgery, and the male-to-female ratio was roughly equal among cases (female: 51.9%). Following surgery, 85.2% of patients experienced subarachnoid hemorrhage (SAH), and 22.3% experienced cerebrospinal fluid (CSF) leakage. The mean clinical presentation time of vasospasm ranged from 3 to 13 (mean: 7.5 ± 2.6) days after TSS. At discharge, 51.8% of cases at least had one neurologic complication, including six dead patients (18.5%). A high index of suspicion for vasospasm has been recommended because of the diverse symptoms of this rare condition and the high mortality rate.

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Section: Discussionmentioning

confidence: 51%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Symptomatic Cerebral Vasospasm After Transsphenoidal Adenoma Resection of the Pituitary

et al. 2022

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“…Cerebral vasospasm (CVS) after TSS is an even rarer event with a described incidence of 0.2% in a single-center TSS series ( 4 ). Less than 40 cases have been described in the literature, two-thirds being preceded by PO subarachnoid hemorrhage (SAH), which might result in delayed cerebral ischemia (DCI) and consequent neurologic deterioration ( 5 , 6 , 7 , 8 , 9 , 10 , 11 ).…”

Section: Introductionmentioning

confidence: 99%

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

Elias

Volpon

Azevedo

et al. 2023

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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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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“…Endovascular techniques include coiling, stent protected coiling, covered stents and pipeline devices [ 6 , 9 ] or at least ICA sacrification (coil occlusion). Early diagnosis and treatment of potentially life-threatening complications from ruptured aneurysm, such as subarachnoid hemorrhage, vasospasms or hydrocephalus, have a great impact on the outcome [ 10 , 11 ].…”

Section: Introductionmentioning

confidence: 99%

Internal carotid artery false aneurysm as a fatal complication of transsphenoidal surgery

Sumislawski

Ludwig

Rotermund

et al. 2021

Journal of Surgical Case Reports

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False aneurysm of internal carotid artery (ICA) is a rare but serious vascular complication observed after transsphenoidal pituitary surgery. Here, we present a 41-year-old woman with a pseudoaneurysm in the ophthalmic 1 segment of the left ICA after exoscopic transsphenoidal pituitary surgery. The initially uneventful procedure was complicated by a subarachnoidal hemorrhage 10 days after the surgery, which was confirmed by cranial computed tomography scan. The emergency angiography revealed a pseudoaneurysm of the ophthalmic 1 part of the left ICA. Despite repeated endovascular treatments with a flow diverter and coiling, the patient experienced a re-bleeding with consecutive vasospasms, occlusion hydrocephalus and finally bifrontal intracerebral hemorrhage with fatal outcome. As a conclusion in irregular post-operative courses with for example headache, a post-operative magnetic resonance imaging with vessel presentation using TOF sequence and contrast-enhanced MRA might be recommended in order to detect a possible pseudoaneurysm in an early stage.

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

Abstract: Budnick et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Cited by 10 publications

References 39 publications

Symptomatic Cerebral Vasospasm After Transsphenoidal Adenoma Resection of the Pituitary

Symptomatic Cerebral Vasospasm After Transsphenoidal Adenoma Resection of the Pituitary

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

Internal carotid artery false aneurysm as a fatal complication of transsphenoidal surgery

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