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Cerebral Vasospasms Following Endoscopic Endonasal Surgery for Pituitary Adenoma Resection in the Absence of Post-Operative Subarachnoid Hemorrhage

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Cerebral Vasospasms Following Endoscopic Endonasal Surgery for Pituitary Adenoma Resection in the Absence of Post-Operative Subarachnoid Hemorrhage Journal of Neurology & Stroke Cerebral Vasospasms Following Endoscopic Endonasal Surgery for Pituitary Adenoma Resection in the Absence of Post-Operative Subarachnoid Hemorrhage Case Report Abstract Volume 4 Issue 3 - 2016 The endoscopic endonasal approach (EEA) is a widely accepted and commonly 1 1 utilized approach for the resection of various pituitary tumors. While Paul S Page , Daniel D Kim , Graham C complications commonly include diabetes insipidus, cerebrospinal fluid leaks, Hall2 and Maria Koutourousiou2* and anterior lobe insufficiency cerebral vasospasm may also rarely occur. 1University of Louisville School of Medicine, Louisville, USA 2 Herein, we report the unique case of a 44-year-old female who underwent Department of Neurosurgery, University of Louisville, Louisville, USA uncomplicated endoscopic endonasal surgery for resection of a giant pituitary adenoma. Subsequent cerebral vasospasms were identified on postoperative day *Corresponding author: Maria Koutourousiou, 220 3 and 19 resulting in ischemic strokes with neurological consequence. In the Abraham Flexner Way, Suite 1500, Department of postoperative period, imaging at no point revealed any evidence of subarachnoid Neurosurgery, University of Louisville, Louisville, KY hemorrhage or hematoma formation in the subarachnoid space. Risk factors for 40202, USA, Fax: 502-582-7477; Tel: 502-582-7624; cerebral vasospasm are discussed and the potential for subsequent vasospasm Email: events is addressed. Received: August 07, 2015 | Published: March 08, 2016 Keywords: Stroke; Neurosurgery; Subarachnoid Hemorrhage; Pituitary Adenoma; Vasospasm; Endoscopic Endonasal Surgery Abbreviations: EES: Endoscopic Endonasal Surgery; CSF: [5]. Symptoms may present as a variety of neurological changes Cerebral Spinal Fluid; SAH: Subarachnoid Hemorrhage; aSAH: occurring as early as a few hours to 13 days after hemorrhage Aneurysmal Subarachnoid Hemorrhage; MRI: Magnetic onset [6]. Despite advances in management, it is reported that Resonance Imaging; EEA: Endoscopic Endonasal Approach; 25%-50% of vasospasm survivors demonstrate at least some BMI: Body Mass Index; ECG: Electrocardiogram; CTA: Computed residual disability and death may occur in up to 23% [7,8]. Tomography Angiography; CT: Computed Tomography; Though the exact mechanism of vasospasm is unclear, vascular IVH: Intraventricular Hemorrhage; FSH: Follicle Stimulating Hormone; LH: Luteinizing Hormone; TSH: Thyroid Stimulating is believed to be intimately involved in addition to genetic Hormone; GH: Growth Hormone; ACTH: Adrenocorticotropin inflammation, resulting from extravascular clot formation, Hormone; TCD: Transcranial Doppler; EVD: Extraventricular In addition to cases of SAH, vasospasm has also been Drain; GCS: Glasgow Coma Scale (GCS) influences and dysfunctional autoregulation. reported, though rarely, as a potential complication of pituitary Introduction adenoma resection. Cases of vasospasm after pituitary resection have been reported in a variety of surgical approaches including Pituitary adenomas are among the most common primary transsphenoidal, transcranial, fronto-temporal, and frontal intracranial tumors in adults occurring in up to 15% of pituitary approaches [9-11]. While the exact etiology is unknown, it is glands observed at autopsy and 20% of radiological exams [1]. suspected that mechanical manipulation of the vasculature, Endoscopic endonasal surgery (EES) is a commonly utilized irritation by introduced packing materials, release of vasoactive and generally well-tolerated technique for the transsphenoidal mediators from the hypothalamus, and intraoperative blood removal of such tumors. Despite its widespread practice EES for loss, may all play roles in this response [12,13]. According to a pituitary resection is not without its complications. Commonly recent systematic review of vasospasm cases following pituitary encountered complications include diabetes insipidus (7.0%), surgery, 70% of pituitary adenoma resections developing and/or intracranial hematoma with 23% requiring surgical lessepistaxis common (1.7%), complications anterior lobe such insufficiency as cerebrovascular (1.3%), orvasospasm cerebral evacuation.vasospasm Thedemonstrated most common the presentingpresence ofsymptoms significant of theseSAH andspinal hemorrhagic fluid leakage stroke (0.6%) secondary[2]. In addition to vascular to these complications,damage have patients included changes in mental status (56%) and motor been rarely reported [3,4]. Cerebral vasospasm is a well-documented complication of deficitsHerein, (62%) we present[14]. a unique case of two subsequent strokes subarachnoid hemorrhage (SAH) occurring in 67% of such cases resulting from cerebral vasospasm occurring after giant pituitary Submit Manuscript | http://medcraveonline.com J Neurol Stroke 2016, 4(3): 00130 Copyright: Cerebral Vasospasms Following Endoscopic Endonasal Surgery for Pituitary Adenoma 2/5 Resection in the Absence of Post-Operative Subarachnoid Hemorrhage ©2016 Page et al. adenoma resection without postoperative subarachnoid hemorrhage. While numerous reports of vasospasm occurring and vomiting for four years prior to surgical intervention. Due to after transsphenoidal pituitary adenoma resection have elevatedworsening prolactin daily frontal levels, headaches,the patient wasvision managed difficulties, initially nausea, with bromocriptine therapy, which she eventually became unable to intraoperative blood loss or postoperative SAH on imaging tolerate. After failing medical therapy and symptoms worsened, occurred.been described, Additionally, this tocase our isknowledge unique thisin that is the no only significant reported she was referred to neurosurgery. History and physical exam case of vasospasm occurring twice in the immediate and post- were otherwise unremarkable. Imaging revealed the presence operative period after EES. This case reinforces the importance of a giant pituitary adenoma (Figure 1). The decision was made of maintaining a high-level of suspicion for acute vasospasm in to surgically resect the pituitary adenoma transsphenoidal ly patients who have recently undergone transsphenoidal pituitary through an endoscopic endonasal approach (EEA). resections regardless of the intraoperative blood loss and In addition to a history of obesity and chronic smoking, resulting blood products in the subarachnoid space. the patient’s comorbidities included congestive heart failure, Case Presentation malignant hypertension, rheumatoid arthritis, and diabetes mellitus type 2. Pre-operative Electrocardiogram (ECG) revealed History and examination and possible left atrial enlargement. Pre-operative routine serum A 44-year-old, right-handed, morbidly obese (BMI=44.75) pituitarynormal sinus panel rhythm revealed with normal first-degree results atrioventricularwith the exception block of African-American female smoker initially presented with elevated prolactin levels at 85.9 ng/nL. Figure 1: Pre-operative MRI T1 with contrast axial (A), sagittal (B), and coronal (C) views showing a large multilobular mass with lengthy extensions, vascular encasement, bone involvement, and mass effect. Imaging Computed tomography angiography (CTA) showed no vessel stenosis or occlusion. A leftward displacement of the ACA Pre-operative magnetic resonance imaging (MRI) with vessels, a 3x2x3 mm anterior communicating artery aneurysm, and without contrast revealed a large mass arising from the and a hypoplastic right A1 segment anatomic variant were also pituitary gland with lengthy extensions, vascular encasement, noted. bone involvement, mass effect causing optic nerves/chiasm compression, and hydrocephalus (Figure 1). The lobulated Operation mass lesion arose from the sella with suprasellar extension predominantly towards the right, with measurements of Near total resection of the giant adenoma was achieved with 6.8x5x3.5 cm giving the impression of a giant pituitary adenoma. Lateral extension into the cavernous sinuses was also noted. to the deep location, size, and vascular nature of the adenoma, EES. Though there was some difficulty controlling bleeding due The clivus and sphenoid sinuses also demonstrated tumor blood loss was limited to 300cc requiring no transfusions. involvement. Mass effect upon the right lateral and third ventricle Successful hemostasis was achieved using copious warm water produced a midline shift and obstruction causing dilatation of irrigation and bipolar coagulation. The superior part of the tumor the right lateral ventricle and left frontal horn. to the surrounding anatomy and some residual tumor remained atdid the not posterior descend duringaspect surgeryof the tumor demonstrating bed. Reconstruction firm attachments of the Citation: Page PS, Kim DD, Hall GC, Koutourousiou M(2016) Cerebral Vasospasms Following Endoscopic Endonasal Surgery for Pituitary Adenoma Resection in the Absence of Post-Operative Subarachnoid Hemorrhage. J Neurol Stroke 4(3): 00130. DOI: 10.15406/jnsk.2016.04.00130 Copyright: Cerebral Vasospasms Following Endoscopic Endonasal Surgery for Pituitary Adenoma 3/5 Resection in the Absence of Post-Operative Subarachnoid Hemorrhage ©2016 Page et al. skull base defect was conducted with a vascularized nasoseptal CTs revealed no acute hemorrhage or other abnormal changes for the duration of the patient’s management. flap.Pathological No other complications Examination occurred during surgery. On postoperative day 19 a new area of infarct was noted on routine CT and MRI in the area of the right head of the Immunohistochemistry
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