Acta Neurochir (Wien) (2006) 148: 587–590 DOI 10.1007/s00701-005-0699-8
Case Report Acute spontaneous subdural haematoma after transsphenoidal surgery H. Eloqayli, J. Cappelen, and A. Vik Department of Neurosurgery, University Hospital of Trondheim, Trondheim, Norway Received August 1, 2005; accepted October 26, 2005; published online December 12, 2005 # Springer-Verlag 2005
Summary Only one case of acute spontaneous subdural haematoma (ASSDH) has been reported following transsphenoidal surgery, whereas, another case of chronic SDH has been reported. We present a patient with pituitary apoplexy, who was treated by transsphenoidal surgery. 8 days postoperative he developed an ASSDH requiring immediate surgical evacuation. This case documents the third occurrence of SDH as a complication of transsphenoidal surgery and is the first report of ASSDH that required immediate surgical evacuation. Keywords: Subdural haematoma; transsphenoidal surgery; pituitary adenoma; apoplexy; complication.
Introduction Postoperative subdural haematomas can occur after neurosurgical operations [5, 13], however only two cases have been reported after transsphenoidal surgery for pituitary adenoma. The first case reported by Tanaka et al. [12] was a chronic subdural haematoma which developed 2 months after surgery and was treated nonsurgically. Another case was reported by Sudhakar and Vafidis [11] where an acute spontaneous subdural haematoma (ASSDH) progressed later to chronic phase and was then evacuated surgically. We report a patient who developed an acute subdural haematoma 8 days after transsphenoidal surgery and required immediate surgical evacuation. Case history A 73-year old male presented with headache, which increased gradually with periods of acute worsening. The headache was worse when recumbent and improved
in the sitting posture. It was associated with nausea and vomiting but no papillodema. Initial visual examination was inconclusive due to decreased patient cooperation, however the patient had subjective complaint of decreased vision. Endocrine assessment showed normal pituitary function except low cortisol. Magnetic resonance imaging (MRI) of the brain showed a large sellar mass with suprasellar extension compressing the optic chiasma (Fig. 1). A microscopic transnasal transsphenoidal approach was planned under the diagnosis of pituitary adenoma and the patient was operated on 9 weeks after the intial complaint. Intraoperatively, only organized old haematoma was found and no abnormal tissue suggestive of tumour was seen. Several biopsies were taken but histology did not confirm pituitary tumor. There was peri-operative cerebrospinal fluid (CSF) leakage. A small piece of collagen matrix (DuraGenTM, Integra Neurosciences, Plainsboro, NJ) was placed over the dural opening and strengthened by a layer of microporous polyester urethane dura substitute (Neuro-Patch+). No lumbar drain was inserted at this stage to minimize the risk of pneumocephalus. Fever was observed on the second postoperative day, proven by lumber puncture on the fourth postoperative day to be a bacterial meningitis and treated with antibiotics. There was no detectable CSF rhinorrhoea during first postoperative week, however, on the 8 postoperative day the patient developed a CSF leak and shortly afterwards he started deteriorating, and became comatose with a dilated right-sided pupil. Cerebral computerised tomography (CT) was immediatly performed demonstrating massive air in the frontal subdural space specially the right side, and an acute right
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Fig. 1. Preoperative sagittal and coronal brain MRI showing large sellar mass with suprasellar extension compressing optic chiasm
Fig. 2. Brain CT scan showing intracranial air including subdural space in the right and acute subdural haematoma. Midline shift, dilated left lateral ventricle, and effaced sulci are shown also
frontotemporoparietal subdural haematoma with midline shift, and dilated left lateral ventricle (Fig. 2). Immediate surgical evacuation of the ASSDH and pneumocephalus was performed, followed by microscopic transnasal transsphenoidal duraplasty and closure of the CSF leak with DuraGenTM and Neuro-Patch+, augmented by Fibrin glue. A lumber drain was inserted. On the third postoperative day, the patient was fully awake with no residual neurological deficit. Postoperative cerebral CT showed small air pockets, but no subdural haematoma (Fig. 3). There was no postoperative
Fig. 3. Brain CT scan showing intracranial air pockets and subdural drain, but no subdural haematoma. Normalising of the midline shift and ventricles are shown
CSF leak and the lumbar drain was removed 72 hours after insertion. At follow up 3 months later both clinical and imaging studies disclosed no CSF leak, no haematomas as well as resolution of the subdural air pockets (Fig. 4). The patient was continued on cortisol hormonal replacement. Discussion Pituitary apoplexy is an infrequent complication of pituitary adenomas caused by a hemorrhagic or ischemic infarction and necrosis of the adenomas associated with
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Fig. 4. (A, B) Sagittal and coronal Brain MRI showing midline pituitary stalk, optic chiasm a without compression, pituitary gland in the base of the sella and no tumour
a rapid, rather than gradual, increase in intrasellar contents [2]. Very rarely pituitary apoplexy may also occur in a normal pituitary gland [14]. Medical management may be used in rare cases in which the signs and symptoms are mild and stable, however, in patients with visual or oculomotor lability or an altered level of consciousness, surgical decompression, most commonly through a transsphenoidal approach, should be performed [14]. Treatment also includes immediate initiation of steroid replacement [10]. Since the initial transsphenoidal approach performed in Austria by Schloffer [8], it has become the preferred surgical approach to most pituitary tumours [3, 8]. Nevertheless, complications continue to be associated with this procedure. Some of the commonly described complications for this approach are anterior pituitary insufficiency, diabetes insipidus, meningitis and CSF fistulas with an incidence of iatrogenic CSF rhinorrhoea of up to 3.9% [1]. Pneumocephalus, characterized by the presence of air in the cranium is frequently caused by trauma and surgery. The occurrence of symptomatic pneumocephalus following transsphenoidal surgery is a rare event [6]. Factors predisposing to tension pneumocephalus include: CSF leak, postoperative positive-pressure mask ventilation, large pituitary tumours, and intra-operative lumbar drainage catheters [7]. Surgical drainage of the symptomatic pneumocephalus and repair of any co-existent CSF leak is the mainstay of treatment. Acute subdural haematoma
is usually associated with cerebral contusion or laceration of the bridging veins following a head injury. Cases of ASSDH have also been reported [4, 9]. However, only one case of ASSDH following transsphenoidal surgery has been reported so far. It seems that several predisposing factors contributed to the development of ASSDH in our patient; brain atrophy due the patients age, CSF rhinorrhoea which could lead to negative intracranial pressure, and tension pneumocephalus which can increase the tension on the bridging veins and cause their rupture. Thus, we conclude that close postoperative follow up is essential in elderly patients undergoing transsphenoidal surgery, specially those complicated by a peri-operative CSF leak. References 1. Ciric I, Ragin A, Baumgartner C, Pierce D (1997) Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40(2): 225–236; discussion 236–237 2. Comunas F, Al-Ghanem R, Calatayud Maldonado V (2003) Pituitary apoplexy. Neurocirugia (Astur). 14(6): 504–511 3. Couldwell WT (2004) Transsphenoidal and transcranial surgery for pituitary adenomas. J Neurooncol 69(1–3): 237–256 4. Ishii T, Sawauchi S, Taya K, Ohtsuka T, Takao H, Murakami S, Morooka S, Yuhki K, Abe T (2004) Acute spontaneous subdural hematoma of arterial origin. No Shinkei Geka 32(12): 1239–1244 5. Koizumi H, Fukamachi A, Nukui H (1987) Postoperative subdural fluid collections in neurosurgery. Surg Neurol 1987(2): 147–153
590 6. Satyarthee GD, Mahapatra AK (2003) Tension pneumocephalus following transsphenoid surgery for pituitary adenoma – report of two cases. J Clin Neurosci 10(4): 495–497 7. Sawka AM, Aniszewski JP, Young WF Jr, Nippoldt TB, Yanez P, Ebersold MJ (1999) Tension pneumocranium, a rare complication of transsphenoidal pituitary surgery: Mayo Clinic experience 1976–1998. J Clin Endocrinol Metab 84(12): 4731–4734 8. Schloffer H (1907) Weiterer bericht uber den fall von operiertem hypophysen-tumor. Wien Klin Wochenschr 20: 1075–1078 9. Scott M (1949) Spontaneous nontraumatic subdural hematoma. JAMA 141: 596–602 10. Semple PL, Webb MK, de Villiers JC, Laws ER Jr (2005) Pituitary apoplexy. Neurosurgery 56(1): 65–72; discussion 72–73 11. Sudhakar N, Vafidis JA (2003) Subdural haematoma after transsphenoidal surgery. Br J Neurosurg 17(3): 253–255 12. Tanaka Y, Kobayashi S, Hongo K, Tada T, Kakizawa Y (2002) Chronic subdural hematoma after transsphenoidal surgery. J Clin Neurosci 9(3): 323–325 13. Tanaka Y, Mizuno M, Kobayashi S, Sugita K (1987) Subdural fluid collection following craniotomy. Surg Neurol 1987(4): 353–356 14. Verrees M, Arafah BM, Selman WR (2004) Pituitary tumor apoplexy: characteristics, treatment, and outcomes. Neurosurg Focus 15; 16(4): E6
H. Eloqayli et al.: ASSDH after transsphenoidal surgery I fully agree with your statement that elderly patients undergoing transsphenoidal surgery require close postoperative follow-up, especially in case of CSF leaks. Eelco Hoving Groningen This is a report of a complication following treatment of a postoperative CSF leak from transsphenoidal surgery. What is described is an acute subdural haematoma following overdrainage of CSF via an occult leak following a repair during the operation, presumably causing tearing of subdural draining veins in an elderly man. It so happened that he had a pituitary apoplexy, although I doubt that this is relevant. The authors describe the complication as being the result of the surgery. I can understand why, but I think it is wrong to ascribe the ASDH to the original procedure. I am sure it is the result of an unrecognised CSF leak. Whatever, this is brave! I am sure this is a problem that has happened to many (it has certainly happened to one of my patients in recent history) but I suspect most surgeons do their best to forget things like this. That the authors are not worried by this is to be commended, and I suspect we ought to report more adverse events of this nature as a warning. Michael Powell London
Comments An interesting case is presented concerning an elderly patient who develops an acute subdural haematoma after transsphenoidal surgery.
Correspondence: Eloqayli Haytham, Neurosurgery Department, University Hospital of Trondheim, Olav Kyrres gt. 17, 7006 Trondheim, Norway. e-mail:
[email protected]
