The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
23. Iñigo F, Rojo P, Ysunza A. Aesthetic treatment of Romberg's disease: experience with 35 cases. Br J Plast Surg 1993;46:194–200 24. Vaienti L, Soresina M, Menozzi A. Parascapular free flap and fat grafts: combined surgical methods in morphological restoration of hemifacial progressive atrophy. Plast Reconstr Surg 2005;116:699–711 25. Longaker MT, Siebert JW. Microvascular free-flap correction of severe hemifacial atrophy. Plast Reconstr Surg 1995;96:800–809 26. Yu-Feng L, Lai G, Zhi-Yong Z. Combined treatments of facial contour deformities resulting from Parry-Romberg syndrome. J Reconstr Microsurg 2008;24:333–342 27. Teng L, Jin X, Wu G, et al. Correction of hemifacial atrophy using free anterolateral thigh adipofascial flap. J Plast Reconstr Aesthet Surg 2010;63:1110–1116 28. Hunstad JP, Shifrin DA, Kortesis BG. Successful treatment of Parry-Romberg syndrome with autologous fat grafting: 14-year follow-up and review. Ann Plast Surg 2011;67:423–425 29. Tanna N, Broer PN, Roostaeian J, et al. Soft tissue correction of craniofacial microsomia and progressive hemifacial atrophy. J Craniofac Surg 2012;23:2024–2027
Nonaneurysmal Subarachnoid Hemorrhage Secondary to Transsphenoidal Surgery for Pituitary Adenomas Hansheng Shu, MD,* Xuping Tian, MD,* Hao Wang, MD,* Hui Zhang, MD,* Qiujian Zhang, MD,* Liemei Guo, MD, PhD† Abstract: Nonaneurysmal subarachnoid hemorrhage (SAH) is a rare and severe complication of transsphenoidal surgery for pituitary adenoma (PA). To improve recognition of this complication, we reviewed and examined 4 patients with nonaneurysmal SAH secondary to transsphenoidal surgery for PAs. Furthermore, possible causes contributed to the SAH, and the attention on preventing the occurrence of SAH is reviewed and stressed. Key Words: Nonaneurysmal subarachnoid hemorrhage, transsphenoidal surgery, pituitary adenoma
S
ubarachnoid hemorrhage (SAH) after transsphenoidal surgery (TSS) for pituitary adenoma (PA) is often recognized as an indication of an intracranial aneurysm ruptured, which might be coexisting with PA.1,2 However, nonaneurysmal subarachnoid hemorrhage
(SAH) secondary to TSS, which might imply intracranial vessel injury during TSS, would lead to unfavorable prognosis including hydrocephalus, cerebral vasospasm, and even fatal results.3–6 To improve recognition of this complication, we reviewed and examined 4 patients with nonaneurysmal SAH due to TSS for PAs.
CLINICAL REPORT The clinical data of 243 patients with TSS for PAs in the Department of Neurosurgery, Renji Hospital from November 2011 to March 2014 were reviewed retrospectively. Of the 243 patients, all underwent endoscopic TSS and only 4 patients were found to experience nonaneurysmal SAH after TSS. A summary of the clinical characteristics of the 4 patients is presented in Table 1. All the patients were diagnosed with pituitary macroadenoma with magnetic resonance (MR) contrast before the operation (Figs. 1–4). During the operation, the tumor texture was found to be tenacious in 2 patients and the diaphragma sellae was injured with cerebrospinal fluid (CSF) leak in another 2 patients. The neurologic status of the patients with SAH was assessed using the Hunt-Hess classification, and computed tomographic (CT) angiography (CTA) was performed to rule out the diagnosis of intracranial aneurysm or artery injury. In addition, continuous lumbar drainage was performed to relieve the hydrocephalus in 1 patient, whereas craniotomy was adopted to remove the hematoma in another patient. At discharge, the functional outcomes of the patients were assessed using the Glasgow Outcome Scale (GOS) scores.
Patient 1 This 57-year-old man presented with gradually progressive diplopia for 6 months. Neurologic examination results showed his left adductor difficulties with good visual acuity and visual field. Routine endocrine examination results showed a higher level of prolactin (14.1 μg/mL; normal, 4.5–12.6 μg/mL). Cranial MR results revealed a 2.3 cm 2.0 cm 1.5 cm-sized isointense sellarparasellar mass lesion (Figs. 1A, B). A diagnosis of pituitary macroadenoma was made, and an endoscopic TSS for the tumor was performed. Intraoperatively, the tumor was tenacious and could not be removed by suction and ring curette. Moreover, the diaphragma sellae was injured and a CSF leak occurred. Routinely, sellar packing with fascia and tissue glue was performed and a lumbar drain was inserted after the subtotal removal of the tumor. However, the patient was in somnolence on the first postoperative day and cranial CT scans revealed frontal hematoma and diffuse SAH in the suprasellar region as well as bilateral Sylvian and interhemispheric fissures (Fig. 1C). Emergent CTA was performed, and it did not reveal any aneurysm or internal carotid artery (ICA) injury (Fig. 1D). The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day with GOS score of 4.
DISCUSSION From the *Department of Neurosurgery, The Second Hospital Affiliated Bengbu Medical School, Bengbu, Anhui Province; and †Department of Neurosurgey, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. Received September 15, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to Dr. Liemei Guo, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine. No. 160, Pujian Rd, Pudong District, Shanghai 200127, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001389
e166
Endoscopic TSS is emerging as a minimally invasive and maximally effective procedure for PAs. However, as one of the most severe complications, SAH due to cerebrovascular injury would lead to unfavorable prognosis and even catastrophic results.3–6 To the best of our knowledge, there are only a few studies reporting on the nonaneurysmal SAH due to TSS.3–6 Including our 4 patients described previously, a summary of the clinical characteristics in these series is presented in Table 1. To date, many causes have been proposed to explain the SAH after TSS, including diaphragma sellae injury, hemorrhage of the tumor residuum, and rupture of the dura branch of ICA.3–6 During the tumor removal of TSS, diaphragma sellae or arachnoid membrane is dragged or injured directly or indirectly, and with © 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
TABLE 1. A Summary of the Clinical Characteristics of Our Series and Reports in the Literature on Nonaneurysmal SAH Secondary to TSS Sex
Age, y
Maximal Diameter or Tumor Type, cm
1
M
57
2.3
2 3
F M
65 68
4
F
Goyal et al6 Kuroyanagi et al4 Matsuno et al5
Patient
Zhou et al3
Extent of Tumor Resection
Hunt-Hess
Treatments
GOS (at Discharge)
Subtotal removal
III
Conservative treatment
4
2.7 4.1
Tenacious tumor and injured diaphragma sellae Injured diaphragma sellae Tenacious tumor
Subtotal removal Partial removal
IV III
1 4
50
3.6
Injured diaphragma sellae
Subtotal removal
IV
F —
56 59
3 Nonfunctioning PA
Subtotal removal Subtotal removal
I IV
—
—
Prolactinoma
Injured diaphragma sellae A branch of intradural ICA injured A branch of intradural ICA injured Hemorrhage from tumor residuum in 2 patients and diaphragma sellae injured in 6 patients
Conservative treatment VP shunt to relieve hydrocephalus Craniotomy to remove hematoma Lumbar drain Conservative treatments
Total removal
IV
—
5 Weber syndrome 1 y postoperation 1
—
—
—
—
8 patients
—
Intraoperative Findings
1
The em dash symbol (—) indicates “not in detail”; F, female; ICA, internal carotid artery; M, male; VP, ventriculoperitoneal.
the leakage of CSF, the hemorrhage from the operative region or residuum of the tumor could pass through the diaphragma sellae, enter the subarachnoid space, and extend upward into the ventricles.7 In patients 3 and 4 in the current study and a patient from the study of Goyal et al,6 the postoperative SAH could result from the injured diaphragma sellae. Sometimes, just like in patient 1, the SAH could result in a frontal hematoma that mimics a rupture of an anterior communicating artery aneurysm.7 Generally, the dura surrounding the sella turcica was supplied by the dural branch of the ICA. When the PA grows, the capsule of tumor adheres tightly with the dura branch of the ICA. With the tumor removal, the capsule of tumor moves downward and results in a rupture of the artery. Although spasm of the artery might mask its rupture during operation, late-onset bleeding occurs, which leads to the postoperative SAH.5 Matsuno et al5 first reported this cause for SAH after TSS and supported it with an autopsy. In addition, the one who has anatomy variation of vessels, such as congenital dysplasia of dura vessels surrounding sella turcica or hypertelia of anterior intercavernous sinuses, is susceptible to intracranial vessel injury and postoperative SAH.3 The diagnosis of nonaneurysmal SAH after TSS is not difficult because cranial CT scans were performed routinely on the first postoperative day. Importantly, if SAH exists, emergent digital
angiography, CTA, or MR angiography should be addressed rapidly to rule out the diagnosis of coexisting aneurysm or ICA injury. The management of SAH after TSS was not special. Continuous CSF drainage by ventricular or lumbar puncture should be performed in these patients. With the confirmation of tumor residuum bleeding, intrasellar hematoma removal via TSS or intracranial hematoma removal with craniotomy, if necessary, might be suggested. Vasodilating agent and antispastic treatment should be applied promptly because cerebral vasospasm is frequently associated with TSS and sometimes even fatal.8 The prognosis for patients with SAH after TSS depends mostly on the neurologic condition after SAH and the appropriate treatments for SAH. From the summary of the patients in Table 1, we can find that a higher Hunt-Hess grade is associated with worse outcomes. Furthermore, it was reported that later diagnosis of vasospasm and surgery
FIGURE 2. Images of patient 2. A, Preoperative CT scans of patient 2 showed pituitary macroadenoma. B and C, Post-operative CT scans showed diffuse SAH, with hemorrhage located at suprasellar cistern and cisterna ambiens.
FIGURE 1. Images of patient 1. A and B, Preoperative contrast MR images of patient 1 show pituitary macroadenoma. C, Postoperative CT scans show diffuse SAH, with hemorrhage located in the suprasellar region as well as bilateral Sylvian and interhemispheric fissures, which mimic ruputre of an anterior communicating artery aneurysm. D, Emergent CTA did not reveal any aneurysm or ICA injury.
FIGURE 3. Images of patient 3. A and B, Preoperative contrast MR images of patient 3 show pituitary macroadenoma. C and D, Postoperative CT scans show diffuse SAH, with hemorrhage located at the suprasellar cistern.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e167
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
10. Halvorsen H, Ramm-Pettersen J, Josefsen R, et al. Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir 2014;156:441–449
FIGURE 4. Images of patient 4. A and B, Preoperative contrast MR images of patient 4 show pituitary macroadenoma. C and D, Postoperative CT scans show SAH, with hemorrhage located at the suprasellar cistern and occipital ventricles.
for hematoma evacuation are independently associated with better outcomes.8 Above all, it is most important to prevent the occurrence of SAH after TSS. More attention should be paid to avoiding injury to the diaphragma sellae and protecting the arachnoid membrane between PA and intracranial tissue. Once obvious leakage of CSF occurs, instant sellar floor repair and complete hemostasis should be applied, especially in case of tumor residuum bleeding. Because the texture of PA with fibrous type is tenacious (just as in patients 1 and 3), performance should be careful as well as soft and tumor should be removed using sharp dissection in direct vision and dragging by force should be avoided. Finally, endoscopic TSS should be performed by skilled surgeons who are familiar with the anatomy of the sellar region and transsphenoidal procedures because it was suggested that experience is vital to avoid complications of TSS.9,10 In conclusion, nonaneurysmal SAH is a rare and severe complication of TSS for PA. The injured diaphragma sellae, hemorrhage of the tumor residuum, and rupture of the dura branch of ICA might contribute to the SAH after TSS. Thus, more attention should be paid to protecting the diaphragma sellae, complete hemostasis, as well as careful and soft performance during the procedure of TSS.
REFERENCES 1. Rustagi T, Uy EM, Rai M, et al. Intracranial hemorrhage from undetected aneurysmal rupture complicating transphenoidal pituitary adenoma resection. Conn Med 2011;75:393–398 2. Tsuchida T, Tanaka R, Yokoyama M, et al. Rupture of anterior communicating artery aneurysm during transsphenoidal surgery for pituitary adenoma. Surg Neurol 1983;20:67–70 3. Zhou WG, Yang ZQ. Complications of transsphenoidal surgery for sellar region: intracranial vessel injury. Chin Med J (Engl) 2009;122:1154–1156 4. Kuroyanagi T, Kobayashi S, Takemae T, et al. Subarachnoid hemorrhage, midbrain hemorrhage and thalamic infarction following transsphenoidal removal of a pituitary adenoma. A case report. Neurosurg Rev 1994;17:161–165 5. Matsuno A, Yoshida S, Basugi N, et al. Severe subarachnoid hemorrhage during transsphenoidal surgery for pituitary adenoma. Surg Neurol 1993;39:276–278 6. Goyal N, Basheer N, Suri A, et al. Subarachnoid hemorrhage after transsphenoidal surgery for pituitary adenoma: a case report and review of literature. Neurol India 2012;60:337–338 7. Shahlaie K, Olaya JE, Hartman J, et al. Pituitary apoplexy associated with anterior communicating artery aneurysm and aberrant blood supply. J Clin Neurosci 2006;13:1057–1062 8. Mansouri A, Fallah A, Cusimano MD, et al. Vasospasm post pituitary surgery: systematic review and 3 case presentations. Can J Neurol Sci 2012;39:767–773 9. Charalampaki P, Ayyad A, Kockro RA, et al. Surgical complications after endoscopic transsphenoidal pituitary surgery. J Clin Neurosci 2009;16:786–789
e168
Clinical Studies of the Relationship Between the Complication of Cervicofacial Rhytidectomy Postoperative Nausea and Vomiting and Different Rhytidectomy Sites Ling Zhang, MD,* Jiaqi Wang, MD,* Changyong Chen, MD† Background: It was demonstrated that there are many complications following cervicofacial rhytidectomy, such as hematoma, edema, seromas, ecchymosis, nerve injury, hypertrophic scarring, contour irregularities, infection, nausea, vomiting, and so on. Accordingly, there is a lot of reports about the treatment of complications following rhytidectomy; nonetheless, we find that there is a trifle of research about the complication of postoperative nausea and vomiting. Thus, this study analyzes the cause of postoperative nausea and vomiting and the relationship between it and different sites. Methods: From 2004 to 2008, 108 patients with a mean age of 52 years (range, 30–74 years) underwent cervicofacial rhytidectomy. The approach of operation is local subcutaneous undermining and superficial musculoaponeurotic system double-plication or suture. All data were recorded such as the time when postoperative nausea and vomiting occurred, the duration of the symptom, the frequency of nausea and vomiting, and the antiemetic medicine taken. All cases were grouped according to the different sites of operation. We divided the patients into group A1 and group A2 based on whether forehead rhytidectomy was performed. Meanwhile, we divided the patients into group B1 and group B2 based on whether cervical rhytidectomy was performed. The data of each group were recorded and statistically analyzed. Result: Among 108 patients, postoperative nausea and vomiting occurred in 55 patients. The duration of symptom was about 24 hours. The frequency of vomiting was 1 to 5 times. Besides, nausea and vomiting was characteristic of time limit and the tendency of termination. The ratios of vomiting between groups A1 and A2 were significantly different (P < 0.000 l). The ratios between groups B1 and B2 are of no significant difference (P > 0.05). From the *Plastic Surgery Hospital, Peking Union Medical College; and †Plastic Surgery Department, An Zhen Hospital, Capital Medical University, Beijing, China. Received September 16, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to Jiaqi Wang, MD, Plastic Surgery Hospital, Peking Union Medical College, Beijing,China; E-mail: [email protected] No funding was received for this study. The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001390
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
23. Iñigo F, Rojo P, Ysunza A. Aesthetic treatment of Romberg's disease: experience with 35 cases. Br J Plast Surg 1993;46:194–200 24. Vaienti L, Soresina M, Menozzi A. Parascapular free flap and fat grafts: combined surgical methods in morphological restoration of hemifacial progressive atrophy. Plast Reconstr Surg 2005;116:699–711 25. Longaker MT, Siebert JW. Microvascular free-flap correction of severe hemifacial atrophy. Plast Reconstr Surg 1995;96:800–809 26. Yu-Feng L, Lai G, Zhi-Yong Z. Combined treatments of facial contour deformities resulting from Parry-Romberg syndrome. J Reconstr Microsurg 2008;24:333–342 27. Teng L, Jin X, Wu G, et al. Correction of hemifacial atrophy using free anterolateral thigh adipofascial flap. J Plast Reconstr Aesthet Surg 2010;63:1110–1116 28. Hunstad JP, Shifrin DA, Kortesis BG. Successful treatment of Parry-Romberg syndrome with autologous fat grafting: 14-year follow-up and review. Ann Plast Surg 2011;67:423–425 29. Tanna N, Broer PN, Roostaeian J, et al. Soft tissue correction of craniofacial microsomia and progressive hemifacial atrophy. J Craniofac Surg 2012;23:2024–2027
Nonaneurysmal Subarachnoid Hemorrhage Secondary to Transsphenoidal Surgery for Pituitary Adenomas Hansheng Shu, MD,* Xuping Tian, MD,* Hao Wang, MD,* Hui Zhang, MD,* Qiujian Zhang, MD,* Liemei Guo, MD, PhD† Abstract: Nonaneurysmal subarachnoid hemorrhage (SAH) is a rare and severe complication of transsphenoidal surgery for pituitary adenoma (PA). To improve recognition of this complication, we reviewed and examined 4 patients with nonaneurysmal SAH secondary to transsphenoidal surgery for PAs. Furthermore, possible causes contributed to the SAH, and the attention on preventing the occurrence of SAH is reviewed and stressed. Key Words: Nonaneurysmal subarachnoid hemorrhage, transsphenoidal surgery, pituitary adenoma
S
ubarachnoid hemorrhage (SAH) after transsphenoidal surgery (TSS) for pituitary adenoma (PA) is often recognized as an indication of an intracranial aneurysm ruptured, which might be coexisting with PA.1,2 However, nonaneurysmal subarachnoid hemorrhage
(SAH) secondary to TSS, which might imply intracranial vessel injury during TSS, would lead to unfavorable prognosis including hydrocephalus, cerebral vasospasm, and even fatal results.3–6 To improve recognition of this complication, we reviewed and examined 4 patients with nonaneurysmal SAH due to TSS for PAs.
CLINICAL REPORT The clinical data of 243 patients with TSS for PAs in the Department of Neurosurgery, Renji Hospital from November 2011 to March 2014 were reviewed retrospectively. Of the 243 patients, all underwent endoscopic TSS and only 4 patients were found to experience nonaneurysmal SAH after TSS. A summary of the clinical characteristics of the 4 patients is presented in Table 1. All the patients were diagnosed with pituitary macroadenoma with magnetic resonance (MR) contrast before the operation (Figs. 1–4). During the operation, the tumor texture was found to be tenacious in 2 patients and the diaphragma sellae was injured with cerebrospinal fluid (CSF) leak in another 2 patients. The neurologic status of the patients with SAH was assessed using the Hunt-Hess classification, and computed tomographic (CT) angiography (CTA) was performed to rule out the diagnosis of intracranial aneurysm or artery injury. In addition, continuous lumbar drainage was performed to relieve the hydrocephalus in 1 patient, whereas craniotomy was adopted to remove the hematoma in another patient. At discharge, the functional outcomes of the patients were assessed using the Glasgow Outcome Scale (GOS) scores.
Patient 1 This 57-year-old man presented with gradually progressive diplopia for 6 months. Neurologic examination results showed his left adductor difficulties with good visual acuity and visual field. Routine endocrine examination results showed a higher level of prolactin (14.1 μg/mL; normal, 4.5–12.6 μg/mL). Cranial MR results revealed a 2.3 cm 2.0 cm 1.5 cm-sized isointense sellarparasellar mass lesion (Figs. 1A, B). A diagnosis of pituitary macroadenoma was made, and an endoscopic TSS for the tumor was performed. Intraoperatively, the tumor was tenacious and could not be removed by suction and ring curette. Moreover, the diaphragma sellae was injured and a CSF leak occurred. Routinely, sellar packing with fascia and tissue glue was performed and a lumbar drain was inserted after the subtotal removal of the tumor. However, the patient was in somnolence on the first postoperative day and cranial CT scans revealed frontal hematoma and diffuse SAH in the suprasellar region as well as bilateral Sylvian and interhemispheric fissures (Fig. 1C). Emergent CTA was performed, and it did not reveal any aneurysm or internal carotid artery (ICA) injury (Fig. 1D). The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day with GOS score of 4.
DISCUSSION From the *Department of Neurosurgery, The Second Hospital Affiliated Bengbu Medical School, Bengbu, Anhui Province; and †Department of Neurosurgey, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. Received September 15, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to Dr. Liemei Guo, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine. No. 160, Pujian Rd, Pudong District, Shanghai 200127, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001389
e166
Endoscopic TSS is emerging as a minimally invasive and maximally effective procedure for PAs. However, as one of the most severe complications, SAH due to cerebrovascular injury would lead to unfavorable prognosis and even catastrophic results.3–6 To the best of our knowledge, there are only a few studies reporting on the nonaneurysmal SAH due to TSS.3–6 Including our 4 patients described previously, a summary of the clinical characteristics in these series is presented in Table 1. To date, many causes have been proposed to explain the SAH after TSS, including diaphragma sellae injury, hemorrhage of the tumor residuum, and rupture of the dura branch of ICA.3–6 During the tumor removal of TSS, diaphragma sellae or arachnoid membrane is dragged or injured directly or indirectly, and with © 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
TABLE 1. A Summary of the Clinical Characteristics of Our Series and Reports in the Literature on Nonaneurysmal SAH Secondary to TSS Sex
Age, y
Maximal Diameter or Tumor Type, cm
1
M
57
2.3
2 3
F M
65 68
4
F
Goyal et al6 Kuroyanagi et al4 Matsuno et al5
Patient
Zhou et al3
Extent of Tumor Resection
Hunt-Hess
Treatments
GOS (at Discharge)
Subtotal removal
III
Conservative treatment
4
2.7 4.1
Tenacious tumor and injured diaphragma sellae Injured diaphragma sellae Tenacious tumor
Subtotal removal Partial removal
IV III
1 4
50
3.6
Injured diaphragma sellae
Subtotal removal
IV
F —
56 59
3 Nonfunctioning PA
Subtotal removal Subtotal removal
I IV
—
—
Prolactinoma
Injured diaphragma sellae A branch of intradural ICA injured A branch of intradural ICA injured Hemorrhage from tumor residuum in 2 patients and diaphragma sellae injured in 6 patients
Conservative treatment VP shunt to relieve hydrocephalus Craniotomy to remove hematoma Lumbar drain Conservative treatments
Total removal
IV
—
5 Weber syndrome 1 y postoperation 1
—
—
—
—
8 patients
—
Intraoperative Findings
1
The em dash symbol (—) indicates “not in detail”; F, female; ICA, internal carotid artery; M, male; VP, ventriculoperitoneal.
the leakage of CSF, the hemorrhage from the operative region or residuum of the tumor could pass through the diaphragma sellae, enter the subarachnoid space, and extend upward into the ventricles.7 In patients 3 and 4 in the current study and a patient from the study of Goyal et al,6 the postoperative SAH could result from the injured diaphragma sellae. Sometimes, just like in patient 1, the SAH could result in a frontal hematoma that mimics a rupture of an anterior communicating artery aneurysm.7 Generally, the dura surrounding the sella turcica was supplied by the dural branch of the ICA. When the PA grows, the capsule of tumor adheres tightly with the dura branch of the ICA. With the tumor removal, the capsule of tumor moves downward and results in a rupture of the artery. Although spasm of the artery might mask its rupture during operation, late-onset bleeding occurs, which leads to the postoperative SAH.5 Matsuno et al5 first reported this cause for SAH after TSS and supported it with an autopsy. In addition, the one who has anatomy variation of vessels, such as congenital dysplasia of dura vessels surrounding sella turcica or hypertelia of anterior intercavernous sinuses, is susceptible to intracranial vessel injury and postoperative SAH.3 The diagnosis of nonaneurysmal SAH after TSS is not difficult because cranial CT scans were performed routinely on the first postoperative day. Importantly, if SAH exists, emergent digital
angiography, CTA, or MR angiography should be addressed rapidly to rule out the diagnosis of coexisting aneurysm or ICA injury. The management of SAH after TSS was not special. Continuous CSF drainage by ventricular or lumbar puncture should be performed in these patients. With the confirmation of tumor residuum bleeding, intrasellar hematoma removal via TSS or intracranial hematoma removal with craniotomy, if necessary, might be suggested. Vasodilating agent and antispastic treatment should be applied promptly because cerebral vasospasm is frequently associated with TSS and sometimes even fatal.8 The prognosis for patients with SAH after TSS depends mostly on the neurologic condition after SAH and the appropriate treatments for SAH. From the summary of the patients in Table 1, we can find that a higher Hunt-Hess grade is associated with worse outcomes. Furthermore, it was reported that later diagnosis of vasospasm and surgery
FIGURE 2. Images of patient 2. A, Preoperative CT scans of patient 2 showed pituitary macroadenoma. B and C, Post-operative CT scans showed diffuse SAH, with hemorrhage located at suprasellar cistern and cisterna ambiens.
FIGURE 1. Images of patient 1. A and B, Preoperative contrast MR images of patient 1 show pituitary macroadenoma. C, Postoperative CT scans show diffuse SAH, with hemorrhage located in the suprasellar region as well as bilateral Sylvian and interhemispheric fissures, which mimic ruputre of an anterior communicating artery aneurysm. D, Emergent CTA did not reveal any aneurysm or ICA injury.
FIGURE 3. Images of patient 3. A and B, Preoperative contrast MR images of patient 3 show pituitary macroadenoma. C and D, Postoperative CT scans show diffuse SAH, with hemorrhage located at the suprasellar cistern.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e167
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
10. Halvorsen H, Ramm-Pettersen J, Josefsen R, et al. Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir 2014;156:441–449
FIGURE 4. Images of patient 4. A and B, Preoperative contrast MR images of patient 4 show pituitary macroadenoma. C and D, Postoperative CT scans show SAH, with hemorrhage located at the suprasellar cistern and occipital ventricles.
for hematoma evacuation are independently associated with better outcomes.8 Above all, it is most important to prevent the occurrence of SAH after TSS. More attention should be paid to avoiding injury to the diaphragma sellae and protecting the arachnoid membrane between PA and intracranial tissue. Once obvious leakage of CSF occurs, instant sellar floor repair and complete hemostasis should be applied, especially in case of tumor residuum bleeding. Because the texture of PA with fibrous type is tenacious (just as in patients 1 and 3), performance should be careful as well as soft and tumor should be removed using sharp dissection in direct vision and dragging by force should be avoided. Finally, endoscopic TSS should be performed by skilled surgeons who are familiar with the anatomy of the sellar region and transsphenoidal procedures because it was suggested that experience is vital to avoid complications of TSS.9,10 In conclusion, nonaneurysmal SAH is a rare and severe complication of TSS for PA. The injured diaphragma sellae, hemorrhage of the tumor residuum, and rupture of the dura branch of ICA might contribute to the SAH after TSS. Thus, more attention should be paid to protecting the diaphragma sellae, complete hemostasis, as well as careful and soft performance during the procedure of TSS.
REFERENCES 1. Rustagi T, Uy EM, Rai M, et al. Intracranial hemorrhage from undetected aneurysmal rupture complicating transphenoidal pituitary adenoma resection. Conn Med 2011;75:393–398 2. Tsuchida T, Tanaka R, Yokoyama M, et al. Rupture of anterior communicating artery aneurysm during transsphenoidal surgery for pituitary adenoma. Surg Neurol 1983;20:67–70 3. Zhou WG, Yang ZQ. Complications of transsphenoidal surgery for sellar region: intracranial vessel injury. Chin Med J (Engl) 2009;122:1154–1156 4. Kuroyanagi T, Kobayashi S, Takemae T, et al. Subarachnoid hemorrhage, midbrain hemorrhage and thalamic infarction following transsphenoidal removal of a pituitary adenoma. A case report. Neurosurg Rev 1994;17:161–165 5. Matsuno A, Yoshida S, Basugi N, et al. Severe subarachnoid hemorrhage during transsphenoidal surgery for pituitary adenoma. Surg Neurol 1993;39:276–278 6. Goyal N, Basheer N, Suri A, et al. Subarachnoid hemorrhage after transsphenoidal surgery for pituitary adenoma: a case report and review of literature. Neurol India 2012;60:337–338 7. Shahlaie K, Olaya JE, Hartman J, et al. Pituitary apoplexy associated with anterior communicating artery aneurysm and aberrant blood supply. J Clin Neurosci 2006;13:1057–1062 8. Mansouri A, Fallah A, Cusimano MD, et al. Vasospasm post pituitary surgery: systematic review and 3 case presentations. Can J Neurol Sci 2012;39:767–773 9. Charalampaki P, Ayyad A, Kockro RA, et al. Surgical complications after endoscopic transsphenoidal pituitary surgery. J Clin Neurosci 2009;16:786–789
e168
Clinical Studies of the Relationship Between the Complication of Cervicofacial Rhytidectomy Postoperative Nausea and Vomiting and Different Rhytidectomy Sites Ling Zhang, MD,* Jiaqi Wang, MD,* Changyong Chen, MD† Background: It was demonstrated that there are many complications following cervicofacial rhytidectomy, such as hematoma, edema, seromas, ecchymosis, nerve injury, hypertrophic scarring, contour irregularities, infection, nausea, vomiting, and so on. Accordingly, there is a lot of reports about the treatment of complications following rhytidectomy; nonetheless, we find that there is a trifle of research about the complication of postoperative nausea and vomiting. Thus, this study analyzes the cause of postoperative nausea and vomiting and the relationship between it and different sites. Methods: From 2004 to 2008, 108 patients with a mean age of 52 years (range, 30–74 years) underwent cervicofacial rhytidectomy. The approach of operation is local subcutaneous undermining and superficial musculoaponeurotic system double-plication or suture. All data were recorded such as the time when postoperative nausea and vomiting occurred, the duration of the symptom, the frequency of nausea and vomiting, and the antiemetic medicine taken. All cases were grouped according to the different sites of operation. We divided the patients into group A1 and group A2 based on whether forehead rhytidectomy was performed. Meanwhile, we divided the patients into group B1 and group B2 based on whether cervical rhytidectomy was performed. The data of each group were recorded and statistically analyzed. Result: Among 108 patients, postoperative nausea and vomiting occurred in 55 patients. The duration of symptom was about 24 hours. The frequency of vomiting was 1 to 5 times. Besides, nausea and vomiting was characteristic of time limit and the tendency of termination. The ratios of vomiting between groups A1 and A2 were significantly different (P < 0.000 l). The ratios between groups B1 and B2 are of no significant difference (P > 0.05). From the *Plastic Surgery Hospital, Peking Union Medical College; and †Plastic Surgery Department, An Zhen Hospital, Capital Medical University, Beijing, China. Received September 16, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to Jiaqi Wang, MD, Plastic Surgery Hospital, Peking Union Medical College, Beijing,China; E-mail: [email protected] No funding was received for this study. The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001390
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
