Successful treatment of suprasellar tumors associated with poor brain blood perfusion by severe intracranial arterial stenosis: two case reports

Abstract

Background: Treatment strategy to prevent perioperative cerebral infarction in patients with asymptomatic severe stenosis of the internal carotid artery is not fully established.

Case presentation: Two patients were treated for skull base tumor in the presence of severe stenosis of the internal carotid artery, unilateral in one patient and bilateral in the other patient. Both patients were asymptomatic but had reduced vascular reserve capacity. The extended transsphenoidal approach was planned avoiding the low perfusion pressure region, with only conventional methods of maintaining blood pressure and PaCO2 rather than performing prophylactic vascular reconstruction surgery, and successful tumor removals were achieved without causing further neurological or radiological deficits.

Conclusion: If the surgical route is planned to avoid the distribution of stenotic vessels and low perfusion pressure, prophylactic vascular reconstruction surgery would be unnecessary. Although more experiences based on sub-classified etiology for internal carotid artery stenosis are required, various types of operations including intracranial-extracranial vascular surgery might be justified based on this principle.

Figure 1

Case 1. Coronal (a) and sagittal (b) head MR images with contrast medium showing a well-demarcated skull base tumor, and abnormal mesh-like enhancement around the right ICA terminal and at the distal portion of the ACA. MR angiogram showing severe stenoses of the bilateral ICA terminals and moyamoya vessels (c).

Figure 2

Iodine-123 N-isopropyl-p-iodoamphetamine single photon emission computed tomography scans revealing severe reduction of cerebral blood flow especially in the right hemisphere, and the steal phenomenon bilaterally after injection of acetazolamide.

Figure 3

Case 1. Postoperative coronal (a) and sagittal (b) MR images revealing gross total removal of the tumor.

Figure 4

Case 2. Coronal (a) and sagittal (b) head MR images with contrast medium showing a dumbbell-shaped, partially solid and partially cystic tumor extending from the suprasellar cistern to the third ventricle. MR angiogram showing showed severe stenosis of the right ICA in the cavernous portion, and both A1 and M1 were only faintly visualized (c).

Figure 5

Iodine-123 N-isopropyl-p-iodoamphetamine single photon emission computed tomography scans revealing slight reduction of cerebral blood flow in the right hemisphere, and the vascular reserve capacity was markedly reduced after injection of acetazolamide.

Figure 6

Case 2. Postoperative coronal (a) and sagittal (b) MR images revealing gross total removal of the tumor.