Resident Mayo Clinic Jacksonville, Florida, United States
Introduction: Cerebral vasospasm is commonly observed after aneurysmal subarachnoid hemorrhage, but is a rare complication after resection of skull base tumors, with only a few cases reported.
Methods: A 51-year-old male presented with transient right-eye vision abnormalities; brain MRI revealed a large sellar/suprasellar mass (5.5cm max diameter), extending into the left temporal lobe, with associated large reactive cyst, and displacement of the left M1. He underwent a left orbitozygomatic craniotomy, with resection of a large portion of the suprasellar component. Pathology consistent with pituitary adenoma, gonadotroph-type. On POD#4 he developed acute changes in his exam, with aphasia and right arm hemiparesis.
Results: Given the concern for acute ischemic stroke or vasospasm, STAT head CTA/CTP was obtained, which revealed left MCA-M1 mid-segment focal high-grade stenosis or vasospasm, with good collateralization within the distal left MCA territory from an ACoM and robust STA; CTP consistent with a large area of left MCA territory acute ischemia. Cerebral angiogram confirmed left M1 mid-segment luminal irregularity, which did not improve after injection of verapamil, suspicious for dissection. Interventions considered included stent placement or EC-IC bypass, but given the high risk for reflow ICH, recommendation was made for aggressive medical management (nimodipine, MAP>100mmHg requiring norepinephrine gtt, ASA 325mg). His symptoms resolved with medical management. However, his exam remained MAP/perfusion dependent as evidenced by recurrence of drift and dysarthria when MAP dropped below 80mmHg. He was monitored with near-infrared spectroscopy and serial transcranial doppler-US and underwent a repeat angiogram on POD#17 that revealed complete occlusion of the left M1, with left MCA territory supplied by pial collaterals from ACA. On POD#22 he was weaned off norepinephrine, with resolution of his aphasia and transferred out of ICU.
Conclusion : This is the first case of acute hemispheric “adaptive collateralization” outside of high-grade carotid occlusion and Moya Moya patient populations without requiring EC-IC bypass.
