A patient who developed complications relating to intracranial arterial vasospasm following transcranial removal of a pituitary adenoma with pituitary apoplexy
is reported. A 23-year-old female was admitted because of headache. Computed tomography (CT) and magnetic resonance (MR) imaging revealed a pituitary adenoma with suprasellar extension and pituitary apoplexy and sinusitis in the right maxillary and ethmoid sinuses. A transcranial approach was selected because of active sinusitis. A large, pink intra- and suprasellar neoplasm and intratumoral clot were removed smoothly. Postoperatively, the patient remained stuporous and showed right hemiplegia. Angiography demonstrated stenosis of the left internal carotid artery and severe spasm of perforating arteries from the left middle cerebral artery. Large pituitary adenoma with pituitary apoplexy requires careful perioperative management, with particular attention paid to the surgical approach and procedures

Karasawa, Jun

Kobitsu, Kunihiko

Nakase, Hiroyuki

Ohnishi, Hideyuki

Sato, Naoki

Touho, Hajime

English

Global Institutional repository of Nara Medical University

(132) 奈医誌. (J. N ara Med. As.) 45， 132~ 137， 1994 POSTOPERATIVE VASOSPASM IN PITUITARY ADENOMA WITH PITUITAR Y APOPLEXY HIROYUKI N AKASE The 2nd Depart叩 ent01 Suγgery， Nara Medical University HIDEYUKI OHNISHI， HAJIME TOUHO， NAOKI SATO， KUNIHIKO KOBITSU and JUN KARASAWA Department 01 Neurosurgeη" Osaka Neurological Insti似たAbstract: A patient who developed complications relating to ihtracranial arterial vasospasm following transcranial removal of a pituitary adenoma with pituitary apoplexy is reported. A 23-year-old female was admitted because of headache. Computed tomography (CT) and magnetic resonance (MR) imaging revealed a pituitary adenoma with suprasellar extension and pituitary apoplexy and sinusitis in the right maxillary and ethmoid sinuses. A transcranial approach was selected because of active sinusitis. A large， pink intra-and suprasellar neoplasm and intratumoral clot were removed smoothly. Postoperatively， the patient remained stuporous and showed right hemiplegia. Angiography demonstrated stenosis of the left internal carotid artery and severe spasm of perforating arteries from the left middle cerebral artery. Large pituitary adenoma with pituitary apoplexy requires careful perioperative management， with particular attention paid to the surgical approach and procedures. lndex Terms pituitary adenoma， apoplexy， vasospasm INTRODUCTION Vasospasm remains one of the most difficult conditions confronted by neurosurgeons. Vasospasm after subarachnoid hemorrhage is a common and well-known entity， but vasospasm in association with pituitary adenoma has been rarely reported1-10)6. We describe a patient who developed complications relating to intracranial arterial vasospasm following transcranial removal of pituitary adenoma with apoplexy. CASE REPORT A 23-year-old female was admitted to Osaka N eurological Institute because of headache that had persisted for one month prior to admission. N eurological abnormalities on admission included left temporal hemianopsia. Her serum growth hormone level was 15.0 ng/ml (nor凶mal， < 5 mg/m])and prolactin level 29.4 ng/ml (normal， < 15 ng/m]). Other tests of endocrine function were normal on baseline and provocative testing. General physical examination was Author's present address: Hiroyuki Nakase， Department of Neurosurgery， Nara Medical University， 840 Shijo-cho， Kashihara 634， Nara， Japan Postoperative vasospasm in pituitary adenoma with pituitary apoplexy (133) normal. Computed tomography CCT) showed a slight high density with partial low density mass in the intra-and suprasellar lesion with no contrast medium enhancement， and showed sinusitis in the right maxillary and ethmoid sinuses. Magnetic resonance CMR) imaging revealed an intrasellar and suprasellar inhomogenous hyperintensity mass on Tl weighted imagesCWI)and T2WI which was compatible with pituitary apoplexy CFig. 1)， and no gadoliniumdiethylenetriaminepenta-acetic acid CGd-DTPA) enhancement was seen. Angiogra. phy via femoral catheterization demonstrated stretching of the horizontal portion of the bilateral anterior cerebral arteries， suggesting suprasellar extension. The right sinusitis was active， and culture was positive， demonstrating Staphylococcus aureus， so a transcranial approach was selected. A left frontotemporal craniotomy was carried out. A large， pink suprasellar neoplasm was encountered beneath the chiasm and both optic nerves. The tumor and intratumoral clot were removed easily with minimal bleeding. A normal pituitary gland was compressed superiorly by the tumor， and the pituitary stalk was seen and could be preserved. Autologous fat was placed into the tumor bed to prevent empty sella syndrome. N 0 vascular spasm was evident at the time of closure. Pathological examination of the specimen demonstrated a chromophobe adenoma. Postoperatively， the patient remained stuporous and showed right hemiplegia. Emergent CT on the day of operation revealed no abnormality CFig. 2)， but emergent angiography demon-Fig. 1. Tl-weighted (TR 600， TE 25 msec) axial (left) and sagital (right) MR imag巴s，d巴monstratingan intrasellar and suprasellar inhomogenously hyperintense lesion which was compatible with pituitary apoplexy. (134) H. N akase， etal strated stenosis of the left internal carotid artery and severe spasm of perforating arteries from the left middle cerebral artery (Fig. 3). No explanation for the clinical deterioration other than the spasm was ever found. She was treated with low molecular dextran， hyperbaric oxygen therapy， glycerin and steroid. One day after operation， the consciousness level was clear， but motor aphasia and the right hemiparesis (2/5) remained. CT revealed a low density area in the right caudate head and frontoparietal lesion (Fig. 4). The symptoms improved gradually， and she was discharged with right mild hemiparesis (4/5) after a three-month admission. DISCUSSION Vasospasm after removal has been previously reported in pituitary adenoma， meningioma， medulloblastoma and acoustic neurinomal). Pituitary adenoma is the most common， and to our knowledge 8 cases2-6) have been reported as a complication following transcranial surgery for pituitary adenoma. The relationship between this sort of vasospasm and the vasospasm observed after subarachnoid hemorrhage has not yet been elucidated5). Several hypotheses can be advanced to explain the occurrence of vasospasm after pituitary surgery: intraoperative mechanical manipulation， intraoperative bleeding， vasoactive substances released from the tumor bed， and hypothalamic injury47). Mawk4) reported three cases of cerebral vascular spasm following transfrontal removal of Fig. 2. Emergent CT just postoperativ巴ly，showing no abnormality巴xceptpostoperative changes. Postoperativ巴 vasospasmin pituitary adenoma with pituitary apoplexy (135) Fig. 3. left: Preoperative angiography， revealing elevation of the left anterior cerebral art巴ry(Al portion). right: Postoperative angiog.raphy， demonstrating spasm of the left internal carotid artery and anterior cerebral artery with poor filing. Perforating arteries from the left ant巴riorand middle cerebral artery were opaque Fig. 4. One day after operation， CT revealed a low density area in the right caudate head and frontoparietal lesion. (136) H. N akase， etal large pituitary neoplasms， and experienced his fourth such case proved fetal in spite of extreme care5). He operated taking care not to open the arachnoid membrane surrounding the lesional internal carotid artery， and the tumor capsule was manipulated minimally. The patient developed progressive cerebral infarction in spite of volume-loading， low molecular weight dextran administration， and heparinization， and died. Mawk speculated that vasoactive substances released from the tumor bed may induce cerebral arterial spasm5). A case of vasospasm associated with pituitary appolexy ofter head trauma was reported3). Pozzati8) reported a case of pituitary apoplexy complicated by bilateral carotid spasm and cerebral infarction without extrinsic carotid compression in a 15-year-old boy， and mentioned that the early occurrence of vasospasm suggested the participation of powerful vasoactive agents released from the tumor. Vasospasm after transsphenoidal removal of a pituitary adenoma has also been reported2ベandit was possible that the free passage of blood from the sella to the basal cisterns was responsible for the subsequent vasospasm and infarction. These cases strongly suggest that vasoactive materials derived from pituitary apoplexy are very hazardous to the cerebral arteries The incidence of pituitary apoplexy var匂sfrom 1.5 % to 27.7 % 11). W akai 11) et al. reported an unexpectedly high incidence of pituitary adenoma (16.6 %) involving asymptomatic hemor-rhage (7.5 %)， and mentioned that any case of major attack with severe symptoms of pituitary apoplexy must be considered as a neurosurgical emergency. Actually， many cases with symptomatic pituitary apoplexy are treated as emergencies， but no case of postoperative vasospasm after emergent operation has been reported in the literature. It may take a definite time for vasoactive materials to be derived from pituitary hemorrhage. Our patient was treated conservatively for vasculopathy and made a considerable neur-ological recovery， possibly because the amount of vasoactive material released was small and early treatment was administered. This is the first report of postoperative vasospasm in pituitary adenoma with pituitary apoplexy demonstrated by MRI preoperatively. If pituitary apoplexy had happened with headache one month prior to admission， two months had passed until operation. We selected a transc REFERENCES 1) Shirasaka， A_， Ninchoji， T.， Uemura， K.， Shinohara， Y.， Kuwahara， T. and Yamazaki，区.: Delayed vasospasm complicated with the postoperative stage of the meningioma-A case report. Neurol目 Surg.21: 745ー749，1993. 2) Goto， T.， Sasanuma， J.， Koshikaykma， H.， Yasuda， T.， Goto， H. and Watanabe， K. : Two cas巴sof vasospasm complicated with the postoperativ巴stag巴ofparas巴lartumor. Proceeding of Spasm Symposium Postoperativ巴 vasospasmin pituitary adenoma with pituitary apoplexy (137) 3: 188-192， 1988 3) Itoyama， Y.， Goto， S.， Miura， M.， Kuratsu， J.， Ushio， Y. and Matsumoto， T.・Intracranialarterial vasospasm associated with pituitary apoplexy after h巴adtrauma. N eurol. M巴d.Chir. (Tokyo) 30: 350 353， 1990. 4) Mawk， J. R.， Ausman， J.I.， Erickson， D. L. and MaxweIl， R. E. : Vasospasm following transcranial removal of large pituitary ad巴nomas. J. Neurosurg. 50: 229-232， 1979. 5) Mawk， J.R. : Vasospasm after pituitary surgery. J. Neurosurg. (LeUer) 58・972，1983 6) Ono， S.， Misumi， S.， Nukui， H. and Kawafuchi， J.: Vasospasm following removal of a large pituitary adenoma by the subfrontal approach. Neurol. Med. Chir. (Tokyo) 21: 609-614， 1981 7) Hyde-Roman， M. D.， Roessmann， U. and Brodlωy， J.S. : Vasospasm following transsphenoidal tumor removal associated with the arterial changes of oral contraception. Surg. N eurol. 20: 120-124， 1983. 8) Pozatti， E.， Frank， G.， Nasi， M. T. and Giuliani， G. : Pituitary apoplexy， bilateral carotid vasospasm， and cerebral infarction in a 15-year-old boy. Neurosurgery 20: 56-59， 1987. 9) Camp， P. E.， Paxton， H. D.， Buchan， G. C. and Gahbauer， H. : Vasospasm after transsph巴noidalhypo. physectomy. Neurosurgery 7: 382-385， 1980目10) Krayenbuhl， H. Beitrag zur Frage des c巴rebralenangiospastischen insultes. Schweiz目 Med.W ochenschr. 90: 961-965， 1960. 11) Wakai， S.， Fukushima， T.， Teramoto， A. and Sano， K. : Pituitary apoplexy: its incid巴nceand clinical significance. J. Neurosurg. 55: 187-193， 1981 

POSTOPERATIVE VASOSPASM IN PITUITARY ADENOMA WITH PITUITARY APOPLEXY

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POSTOPERATIVE VASOSPASM IN PITUITARY ADENOMA WITH PITUITARY APOPLEXY

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