Management of Pheochromocytoma in The Setting of Acute Stroke

Stroke is a rare presenting symptom of pheochromocytoma; therefore, a balance between adequate pre-operative medical blockade and expedition of surgery to minimize the risk of further peri-operative stroke is needed. However, currently there are no established guidelines regarding timing of surgery or length of pre-operative blockade in these patients. We report a case of pheochromocytoma in a 53-year-old woman presenting with a hemorrhagic transformation of an ischemic stroke. We describe the clinical course, diagnosis, and management of our case and then discuss similar cases in the literature as well as optimal pre-operative management. We review all clinical data and describe the patient presentation and treatment. A comprehensive literature review of the topic is discussed. Pheochromocytoma in our patient presented as a combination of stroke, severe hypertension, and tachycardia. A computed tomography scan, evaluation of catecholamine levels, and ¹²³iodine-labeled metaiodobenzylguanidine scan confirmed pheochromocytoma. Hemodynamic stability was achieved after 9 weeks of treatment with selective alpha-blockade and other antihypertensive medications, after which laparoscopic transabdominal adrenalectomy was performed. Despite a normal blood pressure at pre-induction, the patient experienced 6 episodes of severe hypertension intra-operatively. There were no operative complications and hypertension resolved postoperatively. A review of the literature identified 5 similar cases; however, the optimal management of these patients remains unclear. Our case highlights the importance of including pheochromocytoma in the differential diagnosis of patients with stroke. Optimal results may be achieved by ensuring at least 6 weeks of recovery following stroke, and inducing orthostatic hypotension for at least 2 weeks prior to the surgery. Abbreviation: CT computed tomography.