Cerebral vasospasm after resection of an esthesioneuroblastoma: case report and literature review

Abstract

Background: In the last 40 years, there were several reports of symptomatic cerebral vasospasm occurring after resection of brain neoplasms. In most cases, delay in recognition of this complication leads to significant neurologic deterioration postoperatively, regardless of the outcome of surgery. We illustrate in this report a case of cerebral vasospasm after resection of an esthesioneuroblastoma in an adult patient. This is the first report of vasospasm after resection of this neoplasm.

Case description: A 41-year-old woman presented with complaints of headache, dizziness, visual blurring, and diplopia of several-day duration. Funduscopic examination revealed papilledema. Radiological studies revealed a large frontal lobe mass extending through the cribriform plate into the ethmoid sinus with accompanying brain edema. The patient underwent a craniotomy for resection of the neoplasm. Pathological findings were consistent with a high-grade esthesioneuroblastoma. Eleven days postoperatively, the patient's neurologic status declined. Diffusion-weighted MRI of the brain showed an infarct involving mainly the left PCA as well as branches of the left anterior and middle cerebral arteries. Angiography revealed narrowing of the corresponding cerebral vessels consistent with vasospasm. Hypervolemic, hypertensive therapy with nimodipine and corticosteroids were instituted. The patient initially improved but was left with a right homonymous hemianopsia upon discharge 23 days postoperatively.

Conclusions: Delayed neurologic deficit from vasospasm after tumor resection is a complication that is being reported in increasing numbers. These cases involved tumors in or adjacent to the basal cisterns, or surgical approaches that increase the propensity of blood to accumulate intraoperatively or postoperatively in a specific pattern in the basal subarachnoid space. A high index of suspicion for vasospasm should be maintained in patients who develop delayed neurologic deficit, especially when there is evidence of profuse intraoperative bleeding or postoperative blood in the basal cisterns. Early recognition of this phenomenon and early institution of proper therapy can reverse some or all of the neurologic deficit and improve the overall outcome for these patients.