Bilateral Cavernous Sinus Syndrome Resulting from Trendelenburg Positioning in a Patient with Pituitary Macroadenoma

Introduction: Cavernous sinus syndrome is a rare phenomenon, characterized by simultaneous neuropathies of cranial nerves III-VI. Various pathological processes have been reported as precipitating etiologies, including infection, inflammation, carotid-cavernous fistula and other vascular lesions, as well as a range of neoplasms—all of which share the final common pathway of mass effect within the cavernous sinus, where the neural elements converge. We report the first case of bilateral cavernous sinus syndrome attributable to prolonged Trendelenburg positioning during a non-neurosurgical procedure, in the setting of a known pituitary macroadenoma.

Methods: Case report.

Results: A 50-year-old man was incidentally found to harbor a 5-cm pituitary macroadenoma on staging central nervous system imaging during work-up of an aggressive small cell bladder carcinoma (Fig. 1A). Neurologic examination disclosed mild, stable bitemporal hemianopia with preserved visual acuity and no extraocular movement abnormalities. Given the aggressive bladder tumor and minimally symptomatic pituitary lesion, treatment of the malignancy was prioritized, and the patient underwent neoadjuvant chemotherapy followed by robotic-assisted radical cystoprostatectomy—a procedure that required Trendelenburg positioning for more than four hours. Postoperatively, he awoke with complete bilateral ophthalmoplegia with near complete bilateral ptosis, mydriasis and no extraocular movements consistent with bilateral complete III, IV and VI nerve palsies. His visual acuity was unchanged from his preoperative baseline. Repeat MRI demonstrated no evidence of acute hemorrhage, but a striking loss of tumor enhancement, suggestive of acute necrosis with no change in overall tumor volume compared with preoperative imaging (Fig. 1B). He was subsequently taken for transsphenoidal microscopic resection; intraoperatively, a soft, avascular tumor was encountered, gross total resection was achieved, and the skull base was reconstructed in layers using abdominal fat graft, nasoseptal flap, and synthetic fibrin sealant. Final pathology confirmed benign pituitary adenoma with areas of necrosis, and the patient completed an uncomplicated recovery. At one-month follow-up, visual acuity was subjectively preserved, with some improvement in extraocular movements.

Conclusion: We report the first case of bilateral cavernous sinus syndrome resulting from prolonged Trendelenburg positioning in a patient with pituitary macroadenoma. Although rare, this highlights the potential dangers of “head down” surgical positioning for unrelated operations in patients with intracranial pathology—particularly in or around the sella and cavernous sinus.