160 Case Reports / Journal of Clinical Neuroscience 16 (2009) 160–162

Acute subdural hematoma after transsphenoidal surgery

Girish Menon *, Biji Bahuleyan, Suresh Nair

Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India

Received 9 March 2008; accepted 16 April 2008

Abstract

We report the case of a 48-year-old male who developed an acute subdural hematoma after transsphenoidal decompression of a pitu-itary adenoma followed by a lumbar drain to conservatively manage postoperative cerebrospinal fluid rhinorrhoea. An attempt is madeto discuss the risk factors. The need for constant monitoring, early imaging and prompt treatment is stressed.� 2008 Elsevier Ltd. All rights reserved.

Keywords: Subdural hematoma; Transsphenoidal; Pituitary

1. Introduction

Acute subdural hematoma secondary to a cerebrospinalfluid (CSF) leak is a rare but potentially fatal complicationin neurosurgical practice. We present a case report of anacute subdural hematoma that occurred after transsphe-noidal surgery, which is clinically different from the threepreviously published cases.

2. Case report

A 45-year-old male with diabetes presented with pro-gressive dimness of vision in both eyes over 5 years. Hereported a history of occasional occipital headache buthad no history suggestive of any hormonal or hypotha-lamic disturbance. On examination, his visual acuity waslimited to finger counting in both eyes and his visual fieldshowed bitemporal hemianopia. Bilateral optic discs werepale. The results of other systemic examinations were nor-mal. An MRI brain scan revealed a large lobulated sellar-suprasellar lesion suggestive of a pituitary macroadenoma(Fig. 1).

The patient underwent endoscopic assisted transsphe-noidal decompression of the adenoma. Intraoperatively,there was no CSF leak although the arachnoid was seento prolapse into the sella and the sphenoid sinus after tu-mour decompression. The dural defect was repaired withfat and fascia harvested from the abdomen.

On the second postoperative day the patient developedCSF rhinorrhoea and a lumbar drain was inserted underaseptic conditions. The patient complained of a mild head-ache after insertion of the drain. The possibility of pneu-mocephalus was considered but a skull X-ray obtained

with a portable bedside unit ruled this out. His clinicalparameters remained stable. The lumbar catheter drainedaround 500 mL of CSF over two days.

Around 48 h after insertion of the lumbar drain, the pa-tient suddenly became unresponsive and started hyperven-tilating. He was immediately intubated and ventilated. Anemergency CT scan showed a large acute left frontotempo-roparietal subdural hematoma with gross midline shift andmass effect (Fig. 2). The patient underwent emergency cra-niotomy and evacuation of the hematoma.

In spite of the immediate postoperative CT scan show-ing good clearance (Fig. 3), he failed to show significantimprovement and required ventilatory support for nearly10 days. An MRI scan revealed multiple infarcts in thecerebral peduncle, right internal capsule and centrum sevi-ovale. At the time of discharge, nearly one month after thesurgery, he was severely disabled, could just obey simplecommands, had left hemiplegia and was on nasogastrictube-feeding.

3. Discussion

CSF rhinorrhoea following transsphenoidal decompres-sion of a pituitary adenoma is an accepted complicationwith an incidence of 1% to 4%.1,2 Re-exploration andrepacking can be avoided in many patients by conservativemanagement with continuous drainage of CSF through alumbar drain for 48 h to 72 h. Development of subduralhematoma is a rare complication associated with thismanoeuvre. It is extremely important for pituitary sur-geons to be aware of this complication, as delay in detec-tion can be fatal.

Only three prior case reports are available on the devel-opment of subdural hematoma following transsphenoidalsurgery. The first case, reported by Tanaka et al.,3 was achronic subdural hematoma that developed 2 months after

* Corresponding author. Tel.: +91 471 2443152; fax: +91 471 2550728.E-mail address: gmr@sctimst.ac.in (G. Menon).

Fig. 1. Preoperative axial (right) and coronal (left) T1-weighted MRIs showing a large sellar-suprasellar mass lifting the chiasm.

Fig. 2. Axial CT scans showing a large left frontotemporoparietal acutesubdural hematoma causing midline shift and mass effect.

Fig. 3. Axial CT scans obtained postoperatively showing good resolution

Case Reports / Journal of Clinical Neuroscience 16 (2009) 160–162 161

surgery in an elderly man and was treated non-surgicallywith good outcome. The second case, reported by Sudha-kar et al.,1 involved a 77-year-old man who developed anacute subdural hematoma which later progressed to suba-cute and chronic phases and required surgical evacuationon the 15th postoperative day. Eloqayli et al. reported a73-year-old patient who developed an acute subdural

hematoma 8 days after transsphenoidal surgery and re-quired immediate surgical evacuation.2 The present reportdiffers from the previous reports as the patient was rela-tively young (48 years), the hematoma developed almost

of the subdural hematoma and reduction in mass effect.

162 Case Reports / Journal of Clinical Neuroscience 16 (2009) 162–164

48 h after insertion of the drain and, in spite of emergencysurgical evacuation, the patient remained severely disabled.

The factors predisposing to formation of a subduralhematoma are many.1,2 An elderly patient with an alreadyatrophic brain is always a potential candidate. CSF drain-age, initially through the sellar defect and then through thelumbar drain would produce a negative intracranial pres-sure. This can increase the tension forces of blood vesselssuspending the brain to result in a bleed. The third impor-tant factor is tension pneumocephalus, which can developfollowing a rent in the dura and can increase the tensionon the bridging veins, causing their rupture.2

The above factors can vary, as illustrated by our case.The best option, as advised by Sudhakar et al., is to main-tain a high degree of clinical suspicion with a low thresholdto investigate.1 On retrospective analysis of our case, a CT

scan done on the first day following insertion of the lumbardrain, when the patient complained of headache, couldhave helped in early detection of the subdural collection.

To conclude, a lumbar CSF drain should be used judi-ciously in patients developing a CSF leak following trans-sphenoidal surgery. These patients need to be monitoredclosely and an early CT scan should be done at the slightestsuspicion of a problem.

References

1. Sudhakar N, Vafidis JA. Subdural hematoma after transsphenoidalsurgery. Br J Neurosurg 2003;17:253–5.

2. Eloqayli H, Cappelen J, Vik A. Acute spontaneous subdural hematomaafter transsphenoidal surgery. Acta Neurochir (Wien) 2006;148:587–90.

3. Tanaka Y, Kobayashi S, Hongo K, et al. Chronic subdural hematomaafter transsphenoidal surgery. J Clin Neurosci 2002;9:323–5.

doi:10.1016/j.jocn.2008.04.012

Normal pressure hydrocephalus after radiosurgery forsphenoid ridge meningioma

Motohiro Kajiwara *, Kohsuke Yamashita, Tetsuya Ueba, Tomofumi Nishikawa

Department of Neurosurgery, Kishiwada City Hospital, 1001 Gakuhara-cho, Kishiwada City, Osaka 596-8501, Japan

Received 22 January 2008; accepted 2 April 2008

Abstract

Normal pressure hydrocephalus after radiosurgery for meningioma has rarely been reported. We report such a case and discuss therole of radiosurgery in the development of hydrocephalus. A 75-year-old man with a growing tumor underwent linac-based radiosurgery.The tumor received 16 Gy to the 80% isodose line. He exhibited the triad of symptoms of normal pressure hydrocephalus and becamebedridden three months after radiosurgery. Dilated ventricles were demonstrated with MRI. Examination of the cerebrospinal fluidrevealed a high level of protein. The patient underwent a ventriculoperitoneal shunt and recovered well.� 2008 Elsevier Ltd. All rights reserved.

Keywords: Hydrocephalus; Radiosurgery; Complication; Meningioma

1. Introduction

Stereotactic radiosurgery is an effective and noninvasivetreatment for meningiomas.1,2 The high tumor controlrates and low morbidity rates make radiosurgery an effec-tive alternative to surgical removal.1–3 Radiosurgery formeningiomas is associated with low risks of delayed radia-tion injury,1,2 transient radiation-induced edema,1,2 cranialnerve dysfunction,1,4 and radiation-induced neoplasms.5

We report an unusual case of normal pressure hydroceph-alus (NPH) that caused the patient to become bedridden

only 3 months after radiosurgery for sphenoid ridgemeningioma.

2. Case report

A 75-year-old man who had become amnesic and bed-ridden was admitted. Fifteen months before the presentadmission, MRI revealed a 15 mm tumor at the sphenoidridge (Fig. 1). The radiological features indicated meningi-oma. Four months before the present admission, MRIshowed that the tumor had grown to 26 mm. Three monthsbefore the present admission, The patient underwent linac-based radiosurgery, and the tumor received 16 Gy to the

* Corresponding author. Tel.: +81 72 4451000; fax: +81 72 4418812.E-mail address: mkajiwa@comet.ocn.ne.jp (M. Kajiwara).