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Incidence, Risk Factors and Management of Severe Post-Transsphenoidal Epistaxis Q ⇑ Kenneth M

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Incidence, Risk Factors and Management of Severe Post-Transsphenoidal Epistaxis Q ⇑ Kenneth M Journal of Clinical Neuroscience 22 (2015) 116–122 Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Clinical Study Incidence, risk factors and management of severe post-transsphenoidal epistaxis q ⇑ Kenneth M. De Los Reyes a, Bradley A. Gross a, , Kai U. Frerichs a, Ian F. Dunn a, Ning Lin a, Jordina Rincon-Torroella a, Donald J. Annino b, Edward R. Laws a a Department of Neurological Surgery, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA b Department of Otolaryngology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA article info abstract Article history: Among the major complications of transsphenoidal surgery, less attention has been given to severe post- Received 16 June 2014 operative epistaxis, which can lead to devastating consequences. In this study, we reviewed 551 consec- Accepted 2 July 2014 utive patients treated over a 4 year period by the senior author to evaluate the incidence, risk factors, etiology and management of immediate and delayed post-transsphenoidal epistaxis. Eighteen patients (3.3%) developed significant postoperative epistaxis – six immediately and 12 delayed (mean postoper- Keywords: ative day 10.8). Fourteen patients harbored macroadenomas (78%) and 11 of 18 (61.1%) had complex Endoscopic nasal/sphenoid anatomy. In the immediate epistaxis group, 33% had acute postoperative hypertension. Epistaxis In the delayed group, one had an anterior ethmoidal pseudoaneurysm, and one had restarted anticoagu- Management Microscopic lation on postoperative day 3. We treated the immediate epistaxis group with bedside nasal packing fol- Pituitary lowed by operative re-exploration if conservative measures were unsuccessful. The delayed group Risk factors underwent bedside nasal hemostasis; if unsuccessful, angiographic embolization was performed. After Transsphenoidal definitive treatment, no patients had recurrent epistaxis. Ó 2014 Elsevier Ltd. All rights reserved. 1. Introduction to study the incidence, potential risk factors, etiology and sequen- tial management of post-transsphenoidal surgery epistaxis for Transsphenoidal surgery is a well-established approach to sellar pituitary lesions in a large series of patients, operated upon by a and parasellar lesions, notably pituitary adenomas. The endoscopic single surgeon (E.R.L.). An algorithm for stepwise management of technique popularized by Carrau and Jho, Cappabianca and many this complication is offered. others, has afforded improved outcomes as a result of superior illu- mination and panoramic visualization of the pathology [1,2]. Still, 2. Methods major complications, including cerebrospinal fluid leak, internal carotid artery injury and infection can significantly impact surgical A retrospective medical record review was conducted on all outcomes. Much attention has been given to the recognition and endoscopic and microscopic transsphenoidal operations performed management of internal carotid artery injury leading to stroke, by the senior author (E.R.L.) at the Brigham and Women’s Hospital pseudoaneurysm formation, and subarachnoid hemorrhage [3–8]. in Boston, Massachusetts from 1April 2008 through 31 July 2012. Little attention, however, has been given to severe postoperative The Institutional Review Board approved this study (protocol num- epistaxis, which typically originates from the external carotid sys- ber 2012-P-001513/10. Inclusion criteria were defined as patients tem and can lead to devastating consequences. This is the one who developed significant epistaxis that required a therapeutic major complication that can be more common after endoscopic intervention, either immediately after a transnasal transsphenoidal as compared to microscopic transsphenoidal surgery. We aimed operation or with epistaxis in a delayed fashion, up to 30 days after surgery, resulting in readmission to the hospital. Patients with self- limiting minor nose bleeds were excluded. Baseline demographics q This manuscript was presented in abstract form at the annual American and clinical history, including pathology and preoperative and post- Association of Neurological Surgery (AANS) meeting in New Orleans, LA, USA, 26 April to 1 May 2013. operative imaging findings, were recorded. Timing of epistaxis, ⇑ Corresponding author. Tel.: +1 617 732 5500. treatment and intraoperative and angiographic findings were also E-mail address: [email protected] (B.A. Gross). obtained. Categorical variables were compared using Fisher’s exact http://dx.doi.org/10.1016/j.jocn.2014.07.004 0967-5868/Ó 2014 Elsevier Ltd. All rights reserved. K.M. De Los Reyes et al. / Journal of Clinical Neuroscience 22 (2015) 116–122 117 test and continuous variables were compared using a two-sided mucosal dissection. Seven of the 18 (39%) patients had a small t-test. Differences were considered statistically significant if nasal aperture. There were no recurrent or reoperative patients p < 0.05. sustaining this complication. Sinus anatomy and sphenoid type did not significantly differ between patients with immediate and 2.1. Endovascular embolization procedure delayed epistaxis. Standard angiographic techniques were used for patients 3.3. Surgical technique undergoing endovascular embolization under local or general anesthesia. Selective injections of the common and external carotid With regard to the details of the surgery (Table 3), the majority circulation were used to determine if an angiographically visible of patients were treated via the endoscopic technique (89%). Use of cause of epistaxis could be identified, such as a pseudoaneurysm, the three-dimensional endoscope represents an evolution to the or branch cutoffs with and without extravasation. Not infre- adoption of this technique later in the study period. There was quently, no specific target was identified and empiric embolization no significant difference in mean estimated blood loss and cerebro- of both internal maxillary arteries (IMAX) was performed as in the spinal fluid leak rates between patients with immediate and representative case shown in Figure 1. delayed epistaxis. No patient with immediate epistaxis had nasal packing placed at the end of the procedure. 3. Results Management strategies differed between immediate and delayed epistaxis (Fig. 2). Management of those with immediate 3.1. Background and clinical history postoperative epistaxis while in the recovery room involved bed- side nasal packing followed by prompt re-exploration in the oper- Out of 551 transsphenoidal operations, 18 (3.3%) patients devel- ating room if not successful. For patients with delayed epistaxis, oped significant postoperative epistaxis (Table 1). By technique, this the Otorhinolaryngology (ORL) service was consulted, and they occurred after 16 of 457 (3.5%) purely endoscopic cases, one of 34 performed bedside maneuvers including endoscopic packing, bal- (2.9%) surgeries with the operating microscope, and one of 58 loon tamponade, silver nitrate application and/or electrocautery. (1.7%) endoscopic-assisted microscopic cases. Six occurred immedi- If these measures were not successful, then angiography followed ately, and 12 occurred in delayed fashion at a mean postoperative by embolization was performed. day of 10.8 (range, day 3–28). The majority of patients were men (61%); five had a history of hypertension (19%) and only one had a 3.4. Postoperative course in immediate epistaxis history of anti-platelet and anti-coagulant use. No patient had an underlying coagulopathy demonstrated on clinical history or bio- Two of the six patients with postoperative immediate epistaxis chemically. The majority of patients presented with an endocrinop- had developed acute hypertension while in the recovery room athy (44%) followed by visual changes (39%) and/or headache (33%). (33%). Five were treated with immediate nasal packing with Mer- There was no significant difference in demographics or clinical his- ocel (Medtronic Xomed Surgical Products, Jacksonville, FL, USA) tory between the groups with immediate or delayed epistaxis. which was successful in two patients (40%). The remaining three patients, along with another patient with a known, coagulated 3.2. Pathology and anatomy injury to the sphenopalatine artery (SPA) were taken to the operat- ing room. In the latter case, the patient had an episode of acute Fourteen of 18 patients harbored macroadenomas (78%). The hypertension followed by massive epistaxis followed by hypoten- most common tumor type was null cell (33% of cases); however sion requiring transfusion. This was the only patient with immedi- there was no significant difference in tumor types between ate epistaxis requiring a transfusion. Of the remaining three patients with immediate and delayed epistaxis (Table 2). Overall, patients who returned to the operating room, two had definitive 16/18 patients (89%) had a post-sellar sphenoid sinus [9]. Eleven bleeding from the SPA while the other had a generalized, nasal of the 18 (61.1%) had difficult or complex nasal and/or sphenoid mucosal ooze with no underlying coagulopathy or other obvious anatomy: seven patients had friable mucosa (39%), three patients cause, controlled with SurgiFlo (Johnson & Johnson Wound Man- had a complex sphenoid sinus (17%), and two had a significant agement, Somerville, NJ, USA) and tamponade. All patients who obstructive septal deviation (11%) requiring more than the usual returned to the operating room were treated with thrombin Fig. 1. After
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