27-JUNE-2010  MILAD UMAR AL-FANIDY  39 YEARS  HUGE GH-SECRETING PITUITARY ADENOMA WITH INVASION OF THE LEFT CAVERNOUS SINUS.

Anamnesis

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 hypertension.

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 normal.

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 oculomotor nerve.

The patient was sent for check CT-scan, which showed no hematoma and the empty cavities filled with surgicele and air.

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 10.00 pm.

Comments


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 non-responding hyperglycemia.

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 back.