2026 Proffered Presentations
S098: POSTOPERATIVE VASOSPASM AFTER ENDOSCOPIC ENDONASAL PITUITARY ADENOMA RESECTION: AN UNDERRECOGNIZED PHENOMENON
Danielle Golub, MD, MSCI1; Daniele Starnoni, MD1; Miriam M Shao, MD1; Shayan Huda, BS2; Mark B Chaskes, MD3; Margherita Bruni, MD3; Judd H Fastenberg, MD3; Timothy G White, MD1; Thomas W Link, MD, MS1; Mark B Eisenberg, MD1; Amir R Dehdashti, MD1; 1Department of Neurosurgery, Northwell Health, Manhasset, New York, USA; 2CUNY School of Medicine, New York, NY, USA; 3Department of Otolaryngology-Head and Neck Surgery, Northwell Health, Manhasset, NY, USA
Background: Postoperative cerebral vasospasm after endoscopic endonasal surgery (EES) for pituitary adenoma resection is a critical, yet poorly described phenomenon observed in approximately 0.2% of cases. The published experience on postoperative vasospasm in this context remains scarce, but early recognition and intervention is necessary to prevent delayed cerebral ischemia. This exploratory retrospective study aims to better define clinical, surgical, or radiographic predictors of postoperative vasospasm after EES for pituitary adenoma resection.
Methods: Retrospective chart review from 2018–2025 across two academic tertiary care centers of all adult patients who underwent EES for pituitary adenoma resection was performed. All cases with pre- and postoperative imaging available, new infarcts observed on postoperative imaging not explained by another etiology, and final pathology confirming pituitary adenoma were included for further analysis. Any cases in which there was an intraoperative vascular injury were excluded. Tumor morphology was assessed systematically on preoperative MRI, and all postoperative imaging within 30 days was reviewed for new infarcts or hemorrhages by two fellowship-trained neurosurgeons.
Results: Out of 336 cases reviewed, 10 (3.0%) met criteria for suspected postoperative vasospasm—including three cases (0.9%) of angiographically-proven diffuse vasospasm—that were further analyzed. Mean age was 53.6 years (range 22–80 years) with an equal distribution of men and women. There were 8 non-functioning adenomas, 1 prolactinoma, and 1 growth hormone-secreting tumor. Mean maximum tumor diameter was 4.0cm (range 2.3–6.6cm) and 90% of tumors had suprasellar extension with a large mean anterior-posterior suprasellar diameter of 2.8cm. Postoperative hemorrhage was observed in the surgical cavity in 60% of cases, and subarachnoid hemorrhage was seen in 50% of cases. Two patient subgroups were identified; those who developed diffuse vasospasm (n=3), and those with suspected focal vasospasm of small vessels around the surgical cavity (n=7). The diffuse vasospasm cases presented clinically in a delayed fashion (clinical change on mean postoperative day 8) with CT or MRI findings consistent with either watershed distribution or multifocal cortical infarcts. The clinical changes observed in these three patients were altered mental status (n=3), headache (n=2), and respiratory distress (n=1). Two patients underwent urgent angioplasty and intraarterial vasodilator treatments with clinical improvement. The remaining 7 cases with suspected focal vasospasm seen as diffusion restriction in deep structures on early postoperative MRI either had clinically silent infarcts or demonstrated a new neurological deficit immediately postoperatively (Figure 1).
Conclusions: Endoscopic endonasal resection of large or giant pituitary adenomas, especially those with a robust suprasellar component, is associated with a small risk of both focal vasospasm of local perforators and delayed diffuse vasospasm. The suspected incidence of postoperative vasospasm of less than 1% may be an underestimate as patients who present non-focally with an altered sensorium may not undergo timely vessel imaging. While this series is limited by relatively small sample size and descriptive results, the morphological and surgical similarities observed across these cases warrants further consideration of preventative measures such as intraoperative papaverine use, postoperative screening with transcranial dopplers, or delayed CT angiogram in high-risk patients.
