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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 3  |  Page : 337-338

Subarachnoid hemorrhage after transsphenoidal surgery for pituitary adenoma: A case report and review of literature


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission25-Jan-2012
Date of Decision25-Jan-2012
Date of Acceptance27-Feb-2012
Date of Web Publication14-Jul-2012

Correspondence Address:
Ashok K Mahapatra
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.98532

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How to cite this article:
Goyal N, Basheer N, Suri A, Mahapatra AK. Subarachnoid hemorrhage after transsphenoidal surgery for pituitary adenoma: A case report and review of literature. Neurol India 2012;60:337-8

How to cite this URL:
Goyal N, Basheer N, Suri A, Mahapatra AK. Subarachnoid hemorrhage after transsphenoidal surgery for pituitary adenoma: A case report and review of literature. Neurol India [serial online] 2012 [cited 2019 Aug 21];60:337-8. Available from: http://www.neurologyindia.com/text.asp?2012/60/3/337/98532


Sir,

The overall incidence of subarachnoid hemorrhage (SAH) is approximately 9 per 100,000 person-years, and ruptured aneurysms constitute the most common cause of spontaneous SAH. [1] SAH as a result of transsphenoidal surgery for pituitary adenoma is an extremely rare occurrence and, to the best of our knowledge, there have been only three such case reports in the English literature. [2],[3],[4]

A 56-year-old female presented with gradually progressive bilateral visual defect, more in the right eye, for the last 3 years. On examination, the visual acuity in the right eye was hand movements close to face and that in the left eye was 6/9, and fundus examination showed bilateral primary optic atrophy. Perimetry showed bitemporal field defects. Routine biochemistry, coagulation parameters and hormone profile were normal. Magnetic resonance imaging (MRI) revealed a 2 cm × 2 cm × 3 cm-sized isointense sellar-suprasellar mass lesion with enlargement of the sella with significant subfrontal extension [Figure 1]. A diagnosis of non-functioning pituitary macroadenoma was made and a sublabial transsphenoidal tumor decompression was performed. The tumor was soft and could be easily removed by suction and ring curette. Intraoperatively, cerebrospinal fluid (CSF) leak occurred for which sellar packing was performed with fascia and tissue glue and a lumbar drain was inserted. In the post-operative period, the patient's vision improved and she had no complaints. However, the post-operative computed tomography scan revealed residual tumor with intratumoral bleed and SAH in the left sylvian and interhemispheric fissures [Figure 2]. There was no CSF rhinorrhea and the lumbar drain was removed on the second post-operative day. Intra-arterial angiography done on post-operative day 4 did not reveal any pathology such as aneurysm or arteriovenous malformation. Transcranial Doppler showed normal velocities and no evidence of vasospasm. The patient had a normal post-operative course and was discharged on the ninth post-operative day.
Figure 1: Pre-operative magnetic resonance images of the patient reveal a sellar– suprasellar mass lesion with significant subfrontal extension

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Figure 2: Post-operative computed tomography scan of the patient reveals residual tumor with hematoma and subarachnoid hemorrhage in the right sylvian, perimesencephalic and interhemispheric fissures

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Since the advent of modern microneurosurgical techniques, transsphenoidal surgery is widely practiced for pituitary tumors and is considered to be a relatively safe procedure. [4] However, this relatively "blind" procedure is often fraught with complications, the common ones being CSF rhinorrhea, [5] meningitis, diabetes insipidus, septal perforation, paranasal sinusitis and visual disturbances. [6] As for cerebrovascular complications, injury to the carotid artery may lead to pseudoaneurysm formation, carotico-cavernous fistula, carotid occlusion or vasospasm. [7],[8] Review of the English literature showed only three case reports of SAH as a complication of transsphenoidal surgery. [2],[3],[4] Tsuchida et al. reported the case of a 55-year-old male who had a non-functioning pituitary adenoma associated with a previously undetected anterior communicating artery aneurysm that ruptured during transsphenoidal surgery. [2] The authors state that during transsphenoidal surgery, the tumor capsule collapsed abruptly into the sella turcica as the bulk of the tumor was reduced, and this might have exerted traction on the anterior communicating artery aneurysm. The aneurysm was small and not detected on pre-operative bilateral carotid angiography, leaving the possibility that the aneurysm might have developed during the surgical procedure. The patient underwent surgical clipping for the aneurysm and did well after the surgery. Matsuno et al. reported a patient who suffered severe SAH after transsphenoidal surgery for pituitary adenoma (prolactinoma). [3] The patient's condition continued to deteriorate and he died on post-operative Day 21. Kuroyanagi et al. reported a 59-year-old who developed SAH and midbrain and thalamic infarction following transsphenoidal resection of a non-functioning pituitary adenoma. [4] The patient suffered from Weber's syndrome at the end of 1 year after the surgery. It is noteworthy that in both the above-mentioned reports, there was no evidence of intraoperative CSF leak or direct injury to any blood vessels. Post-operative angiograms in both the patients showed no aneurysm. Both these authors speculate that an indirect injury to an artery caused by traction due to descent of the capsule during tumor debulking might have been the cause for SAH. In our patient also, the post-operative angiogram was negative, ruling out any vascular pathology. Intraoperatively, there was injury to the diaphragm sella leading to CSF leak. Also, there was subfrontal extension of the tumor, which might have led to the traction effect on the smaller vessels, while debulking the tumor. Therefore, the possibility arises that blood from the residual tumor or these smaller avulsed vessels might have trickled through the defect in the arachnoid mater and led to SAH. Our patient did not have headache or any clinical deterioration in the post-operative period, unlike the other reported cases.

 
  References Top

1.Spears J, Macdonald RL, Weir B. Perioperative management of subarachnoid hemorrhage. In: Winn HR, editor. Youmans neurological surgery. 6 th ed. Philadelphia: Elsevier Saunders; 2011. p. 3772-90.  Back to cited text no. 1
    
2.Tsuchida T, Tanaka R, Yokoyama M, Sato H. Rupture of anterior communica tingartery aneurysm during transsphenoidal surgery for pituitary adenoma. Surg Neurol 1983;20:67-70.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Matsuno A, Yoshida S, Basugi N, Itoh S, Tanaka J. Severe subarachnoidhemorrhage during transsphenoidal surgery for pituitary adenoma. Surg Neurol 1993;39:276-8.  Back to cited text no. 3
[PUBMED]    
4.Kuroyanagi T, Kobayashi S, Takemae T, Kobayashi S. Subarachnoid hemorrhage, midbrain hemorrhage and thalamic infarction following transsphenoidal removal of a pituitary adenoma. A case report. Neurosurg Rev 1994;17:161-5.  Back to cited text no. 4
[PUBMED]    
5.Goyal N, Borkar S, Agrawal D, Mahapatra AK. Pituitary adenoma presenting with CSF rhinnorhea as the sole symptom. Neurol India 2012;60:307-8.  Back to cited text no. 5
  Medknow Journal  
6.Schwartz M, Swearingen B, Black PM. Transsphenoidal surgery for pituitary tumors. In: Kaye AH, Black PM, editors. Operative Neurosurgery. London: Harcourt Publishers Limited; 2000. p. 671-83.  Back to cited text no. 6
    
7.Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: Results of a national survey, review of literature, and personal experience. Neurosurgery 1997;40:225-37.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.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;56:81-3.  Back to cited text no. 8
[PUBMED]  Medknow Journal  


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