Clinical vasospasm after an extended endoscopic endonasal approach for recurrent pituitary adenoma: illustrative case and systematic review of the literature

Background: Cerebral vasospasm causing delayed cerebral ischemia after transsphenoidal surgery is a rare but life-threatening complication. Reports in the literature after extended endoscopic endonasal approach (EEEA) are scarce. Considering the progressive use of this technique during recent years, a better understanding of the potential adverse effects after this procedure is needed. The aim of this report was to systematically analyze the current literature and discuss management and causes for cerebral vasospasm after EEEA surgery. Methods: We performed a systematic search of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and aimed to discuss relevant risk factors for cerebral vasospasm after extended transsphenoidal surgery. Results: Thirty-four cases of delayed cerebral vasospasm after transsphenoidal surgery were identified. Among these, 4 were operated with an EEEA. We provide an extensive literature review and discuss causes and management of this delayed complication. We further present the case of a young woman who underwent resection for a large suprasellar recurrent pituitary adenoma. Surgery and initial postoperative course were uneventful. On the eighth postoperative day, the patient developed aphasia and brachiofacial paresis. Digital subtraction angiography (DSA) demonstrated cerebral vasospasm, and repeated intra-arterial nimodipine infusion was administrated. The patient recovered completely and was discharged without neurologic deficits. Conclusions: The threshold for DSA after unexplained neurologic deterioration after extended transsphenoidal surgery should be low, and cerebral vasospasm should be treated early and aggressively. Surgeons performing EEEA need to consider the possibility of this delayed complication.