12471 Spasms, Salt And Stroke; A Sequelae Of Post-operative Complications Of Pituitary Adenoma Resection

Abstract Disclosure: I. Jamshed: None. S. Bhandari: None. N. Rastogi: None. Introduction: Pituitary adenomas are neoplasms of pituitary adenonophyseal lineage accounting for approximately 15% of all intracranial tumors. Surgical resection is considered first-line therapy for all adenoma subtypes except prolactinomas. Multiple medical and surgical complications can occur following trans-sphenoidal resection of adenomas. Clinical presentation: A 73-year-old male with history of previously resected pituitary adenoma 6 years ago, presented for elective endoscopic trans-sphenoidal surgery due to recurrence. Postoperatively, the patient exhibited worsening mental status, left-sided hemiparesis and urine output of 8 liters in 2 hours, leading to a severe free water deficit of 1.7 liters. Labs revealed sodium 155(n 136-145 mmol/l) from 149 pre-operatively, serum osmolality 322(275-300 mOsm/ kg) and urine osmolality 768(n 50-1200 mmol/kg), in keeping with diagnosis of Central Diabetes Insipidus. Subsequent CTH showed bilateral cerebral subarachnoid and intraventricular hemorrhage and a central midbrain infarct with accompanying edema. Patient was commenced on intravenous DDAVP and D5W infusion. However, his condition deteriorated, culminating in unresponsiveness. Repeat imaging revealed new bilateral watershed infarctions, likely attributed to diffuse multivessel vasospasm, as seen on CTA head. No clinical improvement was noted with Nimodipine. Hence, the family opted for comfort care measures and the patient expired shortly after. Surgical resection of pituitary tumors, while considered safe, is not without risks, including diabetes insipidus, cerebral hemorrhage, infarction, and vasospasm. Important markers for predicting the onset of DI include serum sodium levels after surgery, the shift in sodium levels from before to after the procedure, and the volume of urine produced prior to administering DDAVP. Subarachnoid hemorrhage and hemiparesis shortly after surgery could be linked to vasospasm that has shown to be responsive to nimodipine. However, nimodipine treatment has proved to be beneficial in those patients who incurred full recovery neurologically (1). Conclusion: The case underscores the inherent risks associated with trans-sphenoidal resection of pituitary tumors. While the procedure is predominantly safe, it can occasionally lead to severe complications contributing to morbidity and mortality. It is imperative that patients are fully briefed on these potential outcomes before undergoing surgery. References: 1.EseonuCI,ReFaeyK,GeocadinRG,Quinones HinojosaA.PostoperativeCerebral Vasospasm Following Transsphenoidal Pituitary Adenoma Surgery. World Neurosurg. 2016 Aug;92:7-14. doi: 10.1016/j.wneu.2016.04.099. Epub 2016 May 4. PMID: 27155378. Presentation: 6/1/2024