Ischemic Complications after Pituitary Surgery: a Report of Two Cases

Abstract

Background Cerebral ischemic complications after pituitary surgery are not frequently reported. These vascular complications may be related to (1) direct trauma to the vessel wall, (2) compression of the internal carotid artery (ICA) due to pituitary apoplexy, (3) vasospasm secondary to subarachnoid hemorrhage or vasoactive tumor extract, or (4) hypothalamic injury.

Patients We describe two cases where major vessel infarcts occurred after removal of pituitary tumor. One case has repeated episodes of thrombembolism probably due to a internal carotid artery (ICA) dissection triggered by minor intraoperative ICA injury during transsphenoidal excision. The other cases had a late-onset cerebral ischemia due vasospasm of middle cerebral artery after transcranial excision of a large pituitary tumor.

Result Both patients had a long hospital stay and were managed successfully with anticoagulant and antiplatelet drugs, aggressive supportive care in the intensive care unit, and rehabilitation.

Conclusion These cases highlight two different mechanisms of infarcts after pituitary surgery. The first case highlights the importance of ICA evaluation before surgery in elderly patients with risk factors, such as chronic smoking, hypertension, and atherosclerotic disease. Even minimal manipulation of the ICA can generate a cascade of thrombembolic events in such patients. The second case highlights the importance of observing the patient of a highly vascular giant pituitary adenoma in the hospital for a longer than usual time. Delayed vasospasm can occur like in aneurysmal subarachnoid hemorrhage and have a good outcome if detected early and managed judiciously.

Keywords

pituitary surgery - carotid artery dissection - vasospasm - transsphenoidal surgery - infarct

• References

• 1 Zhou WG, Yang ZQ. Complications of transsphenoidal surgery for sellar region: intracranial vessel injury. Chin Med J (Engl) 2009; 122: 1154-1156
• 2 Kurschel S, Leber KA, Scarpatetti M, Roll P. Rare fatal vascular complication of transsphenoidal surgery. Acta Neurochir (Wien) 2005; 147: 321-325 , discussion 325
• 3 Aoki N, Origitano TC, al-Mefty O. Vasospasm after resection of skull base tumors. Acta Neurochir (Wien) 1995; 132: 53-58
• 4 Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 1997; 40: 225-236 , discussion 236–237
• 5 Fusco RM, Harrigan MR. Cerebrovascular dissection – A review Part 1: Spontaneus dissection. Neurosurgery 2001; 68: 242-257
• 6 Redekop GJ. Extracranial carotid and vertebral artery dissection: a review. Can J Neurol Sci 2008; 35: 146-152
• 7 Tseng YY, Yang ST, Yeh YS, Yang TC, Wong HF. Traumatic internal carotid artery pseudoaneurysm mimicking sphenoid sinus tumor. Rhinology 2007; 45: 332-334
• 8 Yaghmai R, Olan WJ, O'Malley S, Bank WO. Nonhemorrhagic pituitary macroadenoma producing reversible internal carotid artery occlusion: case report. Neurosurgery 1996; 38: 1245-1248
• 9 Selim M. Perioperative stroke. N Engl J Med 2007; 356: 706-713
• 10 Ng JL, Chan MT, Gelb AW. Perioperative stroke in non-cardiac, non-neurosurgical surgery. Anaesthesiology 2011; 115: 879-890
• 11 Kasliwal MK, Srivastava R, Sinha S, Kale SS, Sharma BS. Vasospasm after transsphenoidal pituitary surgery: a case report and review of the literature. Neurol India 2008; 56: 81-83
• 12 Bejjani GK, Sekhar LN, Yost AM, Bank WO, Wright DC. Vasospasm after cranial base tumor resection: pathogenesis, diagnosis, and therapy. Surg Neurol 1999; 52: 577-583 , discussion 583–584