Abstract
Cerebral vasospasm is a rare life-threatening complication of transsphenoidal surgery (TSS). We report our experience with two cases of symptomatic vasospasm after endoscopic TSS, alongside a systematic review of published cases. Two patients who underwent endoscopic TSS for resection of a tuberculum sella meningioma (case 1) and pituitary adenoma (case 2) developed symptomatic vasospasm. Clinical variables, including demographics, histopathology, the extent of subarachnoid hemorrhage (SAH), diabetes insipidus (DI), day of vasospasm, vasospasm symptoms, vessels involved, management, and clinical outcome, were retrospectively extracted. We subsequently reviewed published cases of symptomatic post-TSS vasospasm. Including our two cases, we identified 34 reported cases of TSS complicated by symptomatic vasospasm. Female patients accounted for 20 (58.8%) of 34 cases. The average age was 48.1 ± 12.9 years. The majority of patients exhibited postoperative SAH (70.6%). The average delay to vasospasm presentation was 8.5 ± 3.6 days. The majority of patients exhibited vasospasm in multiple vessels, typically involving the anterior circulation. Hemodynamic augmentation with hemodilution, hypertension, and hypervolemia was the most common treatment. Death occurred in six (17.6%) of 34 patients. Common deficits included residual extremity weakness (17.6%), pituitary insufficiency (8.8%), and cognitive deficits (8.8%). Symptomatic vasospasm is a rare, potentially fatal complication of TSS. The most consistent risk factor is SAH. Early diagnosis requires a high index of suspicion when confronted with intractable DI, acute mental status change, or focal deficits in the days after TSS. Morbidity and death are significant risks in patients with this complication.
Highlights
BackgroundTranssphenoidal surgery (TSS) is a relatively safe and very effective approach for reaching parasellar and suprasellar tumors
We report here our experience with two cases of symptomatic vasospasm and delayed cerebral ischemia after endoscopic transsphenoidal surgery (TSS) for resection of a tuberculum sella meningioma and a pituitary adenoma
Further complicating this matter is the assumption that neurologic deterioration caused by an expanding hematoma or syndrome of the inappropriate antidiuretic hormone could be treated with stricter blood pressure parameters and volume restriction, which can exacerbate vasospasm
Summary
Transsphenoidal surgery (TSS) is a relatively safe and very effective approach for reaching parasellar and suprasellar tumors. We summarize our review of published cases to highlight the common presenting features, timing, clinical course, and management strategies. How to cite this article Budnick H C, Tomlinson S, Savage J, et al (May 17, 2020) Symptomatic Cerebral Vasospasm After Transsphenoidal Tumor Resection: Two Case Reports and Systematic Literature Review. The medical records for these patients were accessed retrospectively, and the following clinical variables were extracted from each patient’s chart: demographics (age and sex), presenting symptoms, tumor extension, histopathological diagnosis, the documented occurrence of CSF leak, identification of postoperative SAH, postoperative DI, postoperative day (POD) of vasospasm diagnosis, clinical signs and symptoms during vasospasm, diagnostic modality used to confirm vasospasm, the vessels involved, management strategy, and outcome at discharge or last follow-up. Institutional review board/ethics committee approval and patient consent were neither required nor sought for this study
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