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Vasospasm Post Pituitary Surgery: Systematic Review and 3 Case Presentations

Published online by Cambridge University Press:  02 December 2014

Alireza Mansouri ,
Aria Fallah ,
Michael D. Cusimano  and
Sunit Das
Alireza Mansouri*
Affiliation:
Division of Neurosurgery, University of Toronto
Aria Fallah
Affiliation:
Division of Neurosurgery, University of Toronto
Michael D. Cusimano
Affiliation:
Division of Neurosurgery, University of Toronto Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
Sunit Das
Affiliation:
Division of Neurosurgery, University of Toronto Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
*
St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. Email: [email protected]
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Abstract

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Background:

Vasospasm is a known complication of aneurysmal subarachnoid hemorrhage and is a major cause of neurological morbidity and mortality. It is infrequently associated with pituitary adenoma surgery. We report three cases and present a systematic review of the literature with a view towards guiding neurosurgeons in the prevention and management of this complication.

Results:

Including our experience, vasospasm complicating pituitary adenoma surgery has been documented in 29 patients (mean age of 45). All cases occurred in the setting of a postoperative hemorrhage: 21 had a subarachnoid hemorrhage and 10 had a postoperative hematoma requiring evacuation. Initial clinical appearance of delayed cerebral ischemia attributable to vasospasm occurred from postoperative Days 2-13 (most commonly Day 5). Digital subtraction angiography and medical management were the most common diagnostic and therapeutic strategies, respectively. Glasgow Outcome Scores were ≤3 in 59% of cases. Univariate logistic regression identified later diagnosis of vasospasm and surgery for hematoma evacuation to be independently associated with better outcomes.

Conclusion:

Vasospasm should be considered in the differential diagnosis of patients demonstrating altered mental or neurological status following pituitary surgery, particularly if there has been postoperative hemorrhage of any degree. Prompt treatment should be instituted to optimize outcome.

Résumé

RÉSUMÉ Contexte:

Le vasospasme est une complication bien connue de l'hémorragie sous-arachnoïdienne anévrismale et constitue une cause majeure de morbidité neurologique et de mortalité. Il est rarement associé à la chirurgie de l'adénome pituitaire. Nous rapportons 3 observations et nous présentons une revue systématique de la littérature dans l'intention de guider les neurochirurgiens concernant la prévention et le traitement de cette complication.

Résultats:

Le vasospasme comme complication de la chirurgie pour un adénome pituitaire a été documenté chez 29 patients (âge moyen 45 ans), incluant nos observations cliniques. Toutes ces complications sont survenues dans le cadre d'une hémorragie postopératoire: 21 hémorragies sous-arachnoïdiennes et 10 hématomes postopératoires nécessitant une évacuation de l'hématome. Au point de vue clinique, une ischémie cérébrale retardée attribuable au vasospasme a été observée entre le 2e jour et le 13e jour après la chirurgie (le plus souvent au 5e jour). L'angiographie digitale de soustraction et le traitement médical ont été les stratégies diagnostique et thérapeutique les plus fréquemment utilisées. Le score de Galsgow Outcome Scale était de s 3 chez 59 % des patients. L'analyse de régression logistique univariée a montré qu'un diagnostic subséquent de vasospasme et une chirurgie pour évacuation d'un hématome étaient associés de façon indépendante à de meilleurs résultats.

Conclusion:

Le vasospasme devrait être inclus dans le diagnostic différentiel de patients dont l'état mental ou l'état neurologique est altéré après la chirurgie pituitaire, particulièrement s'ils ont présenté une hémorragie postopératoire, quelle qu'en soit l'importance. Un traitement rapide devrait être institué afm d'optimiser le résultat.

Type
Original Articles
Information
Canadian Journal of Neurological Sciences , Volume 39 , Issue 6 , November 2012 , pp. 767 - 773
Copyright
Copyright © The Canadian Journal of Neurological 2012

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