Cerebral Arterial Vasospasm as a Complication in an Endoscopic Transnasal Approach for the Resection of a WHO-I Meningioma. A Case Report

Introduction: Transsphenoidal approach is one of the most used surgical techniques for the treatment of tumors involving the sellar, parasellar, and suprasellar region. This area poses a high-surgical challenge due to its anatomical relationships. Meningiomas of the sphenoid wings are a frequent cause of lesions in these locations, extending to the orbit in some cases. Long-standing meningiomas may grow to involve vascular structures. Arterial cerebral vasospasm (ACV) is a rare complication of transsphenoidal surgery.

Case Report: An otherwise healthy 24-year-old male presented with a 7-year history of headache, right eye proptosis, and decreasing visual acuity, secondary to a mass involving the right sphenoidal wings, the right orbit, and sellar region. He underwent two previous partial resections via a transcranial approach. Pathology demonstrated a WHO-I meningioma. A transnasal transsphenoidal surgical approach was decided due to further deterioration of the visual acuity and progression of ocular proptosis.

During the procedure, the patient presented bleeding from de internal carotid artery (ICA). The bleeding was controlled and the surgery was completed without further complications. Cerebral panangiography revealed interruption of normal flow in the anterior portion of the horizontal segment of the right cavernous ICA, with vascular compensation, making endovascular treatment unnecessary at the time. During the second postoperative day, the patient deteriorated presenting left hemiparesis and dysarthria. A second cerebral panangiography evidenced vasospasm of the left A1 segment of the left ICA with distal flow restriction. The left vasospasm altered the hemodynamic compensation, previously seen in the first angiography. The patient required intra-arterial nimodipine infusion. The following day the patient required a second nimodipine infusion and intravenous vasopressor therapy with noradrenaline for twelve days and milrinone for two days. The patient required physical rehabilitation and comprehensive speech therapy and had complete resolution of the deterioration in his dysarthria and partial improvement of the left hemiparesis.

Conclusion: Cerebral arterial vasospasm is a rare life-threatening complication of endoscopic transnasal transsphenoidal surgery. Ischemic events associated with vasospasm usually occur after the third day in subarachnoid hemorrhages. In our case, vasospasm occurred on second and third postoperative days. The management of cerebral arterial vasospasm secondary to transsphenoidal surgery can be performed as in subarachnoid hemorrhages, our patient showed good symptomatic control. Early physical and speech therapy are essential for the recovery of the associated neurological deficits. Further studies are required to understand the pathophysiology and generate recommendations for the management of vasospasm in this type of surgical intervention.

We present a case report of a resection of a sellar meningioma that compromised the suprasellar region, the right cavernous sinus, and the horizontal segment of the right internal carotid. The carotid was surrounded by the tumor in 360 degrees. Postoperatively, the patient presented with an arterial cerebral vasospasm.

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Artikel online veröffentlicht:
12. Februar 2021