Pituitary adenoma surgeries in COVID-19 era: Early local experience from Egypt

Abstract

Background: The pandemic of COVID-19 has a great impact on all health-care services worldwide. Neurosurgical recommendations are to postpone the endoscopic endonasal pituitary surgeries during the pandemic. We would like to express our experience with urgent pituitary adenomas during the current COVID-19 pandemic.

Methods: In our country, COVID-19 has started to become a paramount problem by March 2020. Nine cases of pituitary adenomas have presented with urgent manifestations. The endoscopic endonasal approach was performed in eight patients, while a craniotomy was selected for a recurrent pituitary adenoma. Pre- and postoperative thorough clinical evaluations with chest CT scans were performed. Other strict infection control measures have been applied.

Results: In 8 weeks duration starting from the past days of February 2020, we have operated on four females and five males of pituitary adenomas. Visual deterioration was the main presenting symptom. The driving factor for surgery was saving vision in eight patients. Fortunately, the postoperative course was uneventful for all patients. No suspected COVID-19 infection has been reported in any patient or health-care team except one patient. In our city, PCR test was routinely not available.

Conclusion: In the era of COVID-19, strict infection control precautions should be employed to limit the possibility of transmission of any possible infection to patient or any of the surgical team. We believe that the risk of getting such infection is not increased by the endonasal approach. Long-term follow-up and large numbers of prospective studies are recommended to delineate the impact of COVID-19 infection on pituitary surgeries.

Keywords: COVID-19; Craniotomy; Endonasal; Endoscopic; Pituitary.

Figure 1:

(Case 5) (a) Two images of coronal section of contrast-enhanced T1WI MRI showing pituitary apoplexy in the form of necrotic cystic part surrounded by homogenous enhancement of fleshy part of the histopathologically confirmed pituitary adenoma. The tumor is pushing the optic chiasm upwards. (b) Two images of sagittal section of contrast-enhanced T1WI MRI showing the sellar and suprasellar two tumor components.

Figure 2:

(Case 3) Non-enhanced CT reformatted mid-sagittal image of the pharyngx, clivus, and sella showing swelling of the back of the tongue obstructing the airway in a patient of growth hormone secreting adenoma. The hollow red arrow points to the expansion of the sellar region by the pituitary adenoma. The well pneumatized sphenoid sinus encourages the endoscopic endonasal approach.

Figure 3:

Preoperative chest CT scan with coronal reformat (identical or alternative to chest X-ray in case of limited resources). This CT scan was performed 2 h before surgery to exclude any abnormality (case 5). As long as there is no suspicion of COVID-19, no further investigations were necessary.

Figure 4:

The management algorithm applied for urgent pituitary adenoma surgeries in setting of limited resources for nonsuspected COVID-19 patients. The same algorithm can be applied after proper COVID-19 testing and proper diagnosis. The close follow-up means regular radiological imaging and visual assessment plus medical treatment for secreting adenomas.