Ischemic complications after pituitary surgery: a report of two cases

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.