Angioplasty is an Effective Treatment for Vasospasm Following Pituitary Apoplexy and Tumor Resection

Abstract

Pituitary apoplexy is a clinical syndrome characterized by acute headache, visual changes, and decreased consciousness occurring in association with hemorrhage or infarct of an existing pituitary adenoma. Surgical management involves tumor resection and decompression of surrounding structures including the optic apparatus. Vasospasm is a rare but potentially devastating complication of pituitary apoplexy. We present a case of pituitary apoplexy in a 28-year-old male treated with emergent endoscopic transsphenoidal resection. On postoperative day seven, following surgical resection, the patient developed neurologic deficits and motor weakness, and severe vasospasm was diagnosed. This is a novel case of intra-arterial verapamil and angioplasty used to treat vasospasm following surgical decompression for pituitary apoplexy. The patient experienced complete recovery of motor deficits following treatment. The authors propose angioplasty as an effective treatment for postoperative vasospasm following transphenoidal surgery for pituitary apoplexy in the presence of focal vessel stenosis.

Keywords: angioplasty; endovascular; pituitary apoplexy; vasospasm; verapamil.

Figure 1. Preoperative head computed tomography (CT) without contrast demonstrating sellar mass extending into the left cavernous sinus.

Figure 2. Widespread cytoplasmic eosinophilia was present in the tumor cells, indicative of ischemic change, and areas of frank necrosis and acute hemorrhage were present.

Figure 3. Postoperative head computed tomography (CT) without contrast demonstrating new acute infarcts involving the bilateral frontal lobes.

Figure 4. Computed tomography (CT) arteriography revealing significant vasospasm in the bilateral distal internal carotid arteries and distal basilar artery.

Figure 5. Angiogram demonstrating the distal right internal carotid artery pre-balloon angioplasty (A) and improved vascular caliber post-balloon angioplasty (B).

Figure 6. Postoperative magnetic resonance imaging (MRI) with contrast demonstrating minimal residual disease, coronal (A) and sagittal (B).