Gupta Rahul, Sharma Arun, Vaishya Richa, Tandon Monica
Department of Neurosurgery, G. B. Pant Hospital, University of Delhi, New Delhi, India.
Department of Biochemistry, G. B. Pant Hospital, University of Delhi, New Delhi, India.
J Neurol Surg A Cent Eur Neurosurg. 2013 Dec;74 Suppl 1:e119-23. doi: 10.1055/s-0032-1328955. Epub 2013 Sep 7.
Cerebral ischemic complications after pituitary surgery are not frequently reported. These vascular complications may be related to (1) direct trauma to the vessel wall, (2) compression of the internal carotid artery (ICA) due to pituitary apoplexy, (3) vasospasm secondary to subarachnoid hemorrhage or vasoactive tumor extract, or (4) hypothalamic injury.
We describe two cases where major vessel infarcts occurred after removal of pituitary tumor. One case has repeated episodes of thrombembolism probably due to a internal carotid artery (ICA) dissection triggered by minor intraoperative ICA injury during transsphenoidal excision. The other cases had a late-onset cerebral ischemia due vasospasm of middle cerebral artery after transcranial excision of a large pituitary tumor.
Both patients had a long hospital stay and were managed successfully with anticoagulant and antiplatelet drugs, aggressive supportive care in the intensive care unit, and rehabilitation.
These cases highlight two different mechanisms of infarcts after pituitary surgery. The first case highlights the importance of ICA evaluation before surgery in elderly patients with risk factors, such as chronic smoking, hypertension, and atherosclerotic disease. Even minimal manipulation of the ICA can generate a cascade of thrombembolic events in such patients. The second case highlights the importance of observing the patient of a highly vascular giant pituitary adenoma in the hospital for a longer than usual time. Delayed vasospasm can occur like in aneurysmal subarachnoid hemorrhage and have a good outcome if detected early and managed judiciously.
垂体手术后的脑缺血并发症报道并不常见。这些血管并发症可能与以下因素有关：（1）血管壁直接损伤；（2）垂体卒中导致颈内动脉受压；（3）蛛网膜下腔出血或血管活性肿瘤提取物继发的血管痉挛；（4）下丘脑损伤。
我们描述了两例垂体肿瘤切除术后发生大血管梗死的病例。一例反复出现血栓栓塞事件，可能是由于经蝶窦切除术中颈内动脉轻微损伤引发的颈内动脉夹层所致。另一例在经颅切除大型垂体肿瘤后，因大脑中动脉血管痉挛出现迟发性脑缺血。
两名患者住院时间均较长，通过抗凝和抗血小板药物、重症监护病房的积极支持治疗以及康复治疗成功治愈。
这些病例突出了垂体手术后梗死的两种不同机制。第一例强调了对于有慢性吸烟、高血压和动脉粥样硬化疾病等危险因素的老年患者，术前评估颈内动脉的重要性。在此类患者中，即使对颈内动脉进行最小程度的操作也可能引发一系列血栓栓塞事件。第二例强调了对于血管丰富的巨大垂体腺瘤患者，在医院观察时间应比通常更长的重要性。迟发性血管痉挛可能像动脉瘤性蛛网膜下腔出血那样发生，若早期发现并合理处理，可取得良好预后。
