Postoperative Paramedian Thalamic Infarction After Sellar and Deep Midline Tumor Surgery: Incidence, Imaging...

To estimate the incidence of postoperative paramedian thalamic infarction after microsurgical resection of sellar and deep midline lesions and characterize its clinical, imaging, and operative features.

In this single-center retrospective cohort, we screened 330 eligible microsurgical resections performed between 2020 and 2025. Patients with newly developed postoperative paramedian thalamic infarction confirmed by DWI and ADC were identified. Perioperative clinical data, lesion distribution, rostral midbrain involvement, the "V sign," and early postoperative CT findings were reviewed. Incidence was estimated with Wilson 95% confidence intervals.

Postoperative paramedian thalamic infarction occurred after 6/330 resections (1.8%; 95% CI, 0.84%-3.91%). Impaired consciousness was recorded in all six patients, with delayed emergence in three. The observed MRI distributions were unilateral paramedian thalamic involvement (3/6), bilateral paramedian thalamic involvement without rostral midbrain extension (2/6), and bilateral paramedian thalamic involvement with rostral midbrain extension (1/6). Recorded operative corridors in affected cases were interhemispheric, transcallosal-interforniceal, or Poppen. The highest descriptive subgroup incidence was in sellar/suprasellar lesions (5/117, 4.3%; 95% CI, 1.84%-9.62%). Extensive basal cisternal blood on early postoperative CT was observed in the patient with bilateral thalamic infarction and rostral midbrain extension.

Postoperative paramedian thalamic infarction after sellar and deep midline lesion surgery is an uncommon but clinically important complication. The observed infarct distributions are consistent with involvement of the thalamoperforating arterial territory. Early DWI/ADC should be prioritized when delayed emergence or impaired consciousness occurs after surgery.