Volume 2, Issue 1 (6-2016)                   IrJNS 2016, 2(1): 25-30 | Back to browse issues page

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Capozza M, Barbagli G, Boschi A, Ashraf-Noubari B, Nappini S, Limbucci N, et al . Delayed Bilateral Symptomatic Vasospasm after Resection of a Skull Base Meningioma: Report on a New Case and Literature Review . IrJNS. 2016; 2 (1) :25-30
URL: http://irjns.org/article-1-35-en.html
1- Consultant
2- Resident , barbagli.giovanni@gmail.com
3- Resident
4- Director
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Background and Importance
Vasospasm is a well-known complication of a subarachnoid hemorrhage (SAH) subsequent to rupture of intracranial aneurysms. Nevertheless, symptomatic vasospasm due to skull base tumors removal is an uncommon event and only few cases have been previously reported following resection of meningioma (1,2). This condition shares clinical features with the one following SAH and depends on the surgical field site, the location of vasospasm (anterior or posterior circulation), the surgical approach performed and the mass of blood clot. Conversely, mortality and morbidity are very high, both for the lack of clinical suspicion and the delayed treatment (3-5). Early diagnosis and prompt therapy planning are mandatory for a successful treatment. 
We performed a complete literature review using proper key-words such as "symptomatic vasospasm", "meningioma resection", "skull base tumors", "postoperative vasospasm", "subarachnoid hemorrhage", "tuberculum sellae", "sphenoid planum", and "nimodipine therapy" on PubMed and MEDLINE databases. We also completely reviewed clinical notes and imaging reports, with the evaluation of short-term clinical follow-up. We considered only cases of symptomatic cerebral vasospasm following a skull base meningioma resection including comprehensive clinical and radiological data.
Case Presentation
Patient’s History and Status
A 40-year-old woman was admitted to our department with recurrent episodes of visual loss associated with right hemifacial pain from some years now. Patient’s history showed positivity to HCV infection and a dysplasia of uterine cervix (cervical intraepithelial neoplasia, grade 2). The patient complained  about pain on the second trigeminal branch which was evoked in association with decreasing visual acuity on right eye. Subsequently, we noted anisocoria with the diameter of right pupilla greater than the left one. 
A gadolinium MRI was performed to assess clinical image and reported a lesion with 3.2 × 2.7 × 3.2 cm, isointense on T1-weight sequences and hyperintense on T2-weight in the region of anterior fossa, showing compatibility with tuberculum and diaphragma sellae mengioma (Figures 1,2). The digital angiography reported a delayed medial impregnation on the clivus region with bilateral A1-segments dislocation which confirmed the suspicious lesion. That study also showed the coexistence of cortical arterio-venous shunt from a parietal feeder of posterior cerebral artery (PCA) with a single shunting by a cortical vein into the sagittal sinus (micro arteiovenous malformation (AVM)).

The patient underwent surgery to remove the lesion. A pterional craniotomy was performed on the right side, and a subfrontal approach revealed a grey and fibrous-like lesion with attachment on the tuberculum and the diaphragma sellae. The right optic nerve was dislocated and thickened and the carotid artery was totally entrapped by the meningioma. After careful dissection of the vascular and neural structures and central debulking, the tumor was completely excised and the dural attachment coagulated with a grade II resection according to Simpson. No intraprocedural bleedings were observed, and hemostasis was simple and effective.  
Post-operative Course
After the operation, the patient underwent a post-operative CT scan without evidence of bleeding at the surgical site. After a few days, a total recovery was observed and the patient was discharged without neurological symptoms on fifth post-operative day. One week later, the patient was re-admitted to our emergency department because of accidental fall and mild head trauma, and underwent a CT scan with a limited hemorrhagic infarction in the surgical site (Figures 3-5).

Second Admission
The patient was mild febrile for two days, without any other evidence of neurological impairment. The next day, she experienced an early clinical worsening with aphasia, left side weakness and severe consciousness deterioration. A transcranial Doppler (TCD) study was performed in order to evaluate the progression of symptoms with the evidence of increased flow velocity in both middle cerebral arteries (MCAs) (307 cm/sec on left side; 228 cm/sec on right side), anterior cerebral arteries (ACAs) (174 cm/sec on left side; 128 cm/sec on right side) and in the posterior circulation (88 cm/sec).
The diagnosis of symptomatic cerebral vasospasm was therefore suspected, and the medical therapy (triple - H by hypertension, hypervolemia, hemodilution) was immediately started associated with the intravenous administration of nimodipine (2mg/h infusion). Subsequently, the patient immediately underwent a digital subtraction angiography (DSA) which confirmed the diagnosis of severe vasospasm in both MCAs, carotid siphons and ACAs, but more evident on the left A1 tract and the right C4 tract of internal carotid artery (Figures 6-9). A slowing down of blood flow was observed within the vascular territory of the left ACA. No sign of vasospasm was detected within the posterior circulation. Then, the patient underwent endovascular treatment by intra-arterial injection of 12 mg of nimodipine through both internal carotid arteries (ICAs) (6 mg for each side), restoring normal blood flow (Figures 10,11). The same procedure was repeated once a day during the next two days (eight mg during the second day and four mg during the third day) based on the TCD follow-up, and a progressive improvement of clinical status was observed. The patient was discharged eight days later, following a negative CT scan for delayed ischemia (Figures 12,13), and the TCD revealed normal values of flow velocity. No neurological deficits were observed at the time of discharge.

We performed a comprehensive literature review using “cerebral vasospasm”, “tumor resection” and “meningioma” as key words. According to our criteria, 14 cases of vasospasm associated with meningioma resection were found; 12 patients of whom were symptomatic (Table 1). To our knowledge, we reported the thirteenth case.
According to the literature, where the patients affected by symptomatic vasospasm following meningioma resection were young (mean age=41 years) (6), our case presented clinical features at the age of 40. In all reported cases, the lesions of the skull base were located close to the basal cisterns. Post-operative bleeding was also observed in all of them. It is also well known that subarachnoid bleeding leads to vasospasm in a mean time of 7-8 days (7). We found, instead, a delayed vasospasm (12th post-operative day) and that late diagnosis could be explained by an unclear clinical onset (blurred frontal lobe syndrome). The high rate of mortality (30%) once patient becomes symptomatic enforces physicians to begin the proper vasospasm management (8-12). This practice consists in the execution of hyper-dynamic therapy, endovascular pharmacological therapy with nimodipine and mechanical angioplasty (where suitable), as soon as possible (3). A correct and early diagnosis combined with a proper medical/endovascular treatment is the only way to obtain a successful management of this potentially fatal occurrence. In a  pathophysiological point of view, a vasospasm following tumor removal may be explained by a peri-operative SAH. In other cases, it might be a consequence of increased sympathetic tone due to diencephalic dysfunction (5) or vasoactive materials from tumor secondary to a surgical site manipulation (2,8,12).
Symptomatic vasospasm following skull base meningioma resection is a very rare and challenging occurrence, with high mortality/morbidity rates. Nevertheless, the data from literature suggest that the key seems to be the early diagnosis associated with a correct treatment. This practice ensures either the survival or the complete recovery of neurological functions in young patients. Symptomatic vasospasm, associated with skull base meningioma resection, has to be a crucial issue for a correct management.
Conflicts of Interest
The authors have no conflicts of interest.

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Type of Study: Case report | Subject: Gamma Knife Radiosurgery
* Corresponding Author Address: Department of Neurosurgery, University of Florence, Largo Palagi 1, Florence, Italy

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