Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
The patient came to the clinic 22-June-2010 complaining
of acromegaly since 2000. The patient was operated
05-June-2009 in Tunis by trans-sphenoidal route, with
partial resection and slight improvement.
The patient has diabetes mellitus and arterial
On examination: the patient is beside bizarre
acromegalic features was neurologically free. He was
left handed with the right hemisphere the dominant one.
He has no convulsions, signs of diabetes insipidus.
MRI of the brain done 20-June-2010 showing huge
pituitary adenoma involving the left cavernous sinus,
eroding the left anterior clinoid and extending down
under it, pushing the left supraclinoid ICA medially,
then engulfing the artery around it at the entire
cavernous part of the artery.
The patient was admitted 26-June-2010 for observation:
Chest X-ray demonstrating cardiomegaly and ECG showing
inverted ST-segment. Thyroid function tests were
elevated. Diabetic scale was started and put under
corrective measures. GH was 28.2 ng/mL. Insulin growth
factor I was 499 ng/mL. Hypernaterimea was noted 135
mmol/L. Osmolality of the blood and urine were within
normal range and the specific gravity of the urine was
Bifrontal monoflap craniotomy was done violating during
that the massively enlarged frontal sinuses. The flap
was reflected to the right ear direction. The lax dura
was incised parallel to the inferior edge of the SSS at
the hypertrophied crista Galli Mobilization of the
olfactory tracts was achieved from both side don to the
trigones. During inspection of the chiasmal region, the
left cavernous sinus was very huge pushing up the left
optic nerve and the supraclinoid part of the left ICA
was shifted medially arising practically from under the
tuberculum sella making a X with the running up the left
optic nerve. The right optic nerve and ICA were shifted
lateral to the right.
The tumor was attacked between the right optic nerve and
the left ICA. It was rubbery in consistency and
massively bleeding. Biopsy was taken for histological
verification, since the first performed operation
lacking such information. The thinned left anterior
clinoid was drilled out and removed. Under the removed
bony structure the tumor wall was noted and attacked
from that point . The tumor here also a rubbery bleeding
one. Piece meal resection of the tumor was achieved
until the left cavernous sinus became an empty cavity.
The lateral wall of the left cavernous sinus was not
violated and preserved. The posterior collapsed wall of
the cavernous sinus was dissected off the left
oculomotor nerve, which was anatomically preserved. No
attempt was done to violate the Liliquist membrane, to
avoid basilar artery reaction. Rand procedure was
performed to expose the antesellar component of the
tumor. This part of the tumor was removed. The 2
cavities were impossible to make them one, taking into
consideration that the left intracavernous part of ICA
was embedded in this part. The upper surface of the
tumor under the left ICA was pushed don and coagulated
and partially resected, but the left ICA was involved
and engulfed high that the left ICA remained directly
under the pushed up left optic nerve, despite the fact,
that the space under the left ICA is empty. The left
olfactory tract was destroyed by massive irrigation
directed to it. Strict heamostasis with the application
of surgicele inside both cavities.
Routine closure of the wound and the patient was
extubated and sent to the ICU. The operation took 10
hours and the patient received 2 units of blood and 2
units of FFP.
In the immediate postoperative examination, the left
pupil was fully dilated due to dissection of the left
The patient was sent for check CT-scan, which showed no
hematoma and the empty cavities filled with surgicele
The patient start to recover and showed psychomotor
irritability with signs of arterial spasm of the left
ICA. Haldol did not help to control irritability and the
patient started to try to leave the bed. There are signs
of hyperglycemia with BS reaching 460 mg/L which was
difficult to control. and the patient showed sweating of
the skin and tendency for hypotension.
It was decided to put back the patient in ventilator to
avoid trauma to the patient due to irritability. During
intubation of the patient , he progressed profound
hypotension and cardiac arrest. Attempts to recover
cardiac functions failed and he was legally dead at
The patient had very huge pituitary
adenoma inside the left cavernous sinus with the intracavernous part
embedded inside the tumor.
Goss continuous manipulations of the left ICA triggered arterial
spasm, which lead to the appearance of postoperative psychomotor
irritability and temporary right sided hemiparesis which resolved
before before planning to put him in ventilator. During intubation
to put the patient in ventilator another surge of diencephalic storm
arouse, the massive volleys to the cardiac system, which brought him
to profound hypotension and cardiac arrest.
The manipulation around the intracavernous part of the ICA was the
only blamed structure for the escalation of such catastrophic event.
Hyperthyroid storm could have place in this difficult condition,
since the preoperative data the day before were elevated and they
were triggered by the surgical trauma and the escalating
Diencephalic, or sympathetic storm also could have place and it was
mostly the cause of his confusion and agitation.
For more information about arterial spasm please click here!
For more information about acromegaly please click here!
for more information about neuroanesthesia difficulties in
acromegaly please click here!
Despite the tragic end of the patient, it is necessary to mention
that the tumor was removed by new modification: The left anterior
clinoid which was eroded by the tumor was removed and the tumor was
removed from that point lateral to both the shifted medially the
left optic nerve and the unusually more shifted the left
supraclinoid ICA. I have the experience with more than 600
subfrontal approaches over 30 years and have patents in surgical
approaches to chiasmal region. It is the first time I could see such
a case with huge intracavernous growth and the first time I made the
attack from the thinned by the tumor the left anterior clinoid. To
my knowledge Rand performed drilling the tuberculum sella to regain
access to the tumor part under it.
In retrospective analysis morbidity and mortality are related with
tumor consistency and richness with blood supply and involvement of
the major arteries inside the tumor.
Mortality and morbidity also escalate with presence of such rich
endocrine and systemic deviations with cardiomyopathy. All these
metabolic deviations could cause different metabolic storms with the
patient going away with the helpless to do anything to bring him
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