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Endoscopic Pituitary Surgery in the Urgent Setting
By Hrayr Shahinian, M.D.
This is the case of a 40-year-old white female with a history of hypertension and infertility who presented to the emergency room at our institution complaining of severe intractable frontal headaches associated with sudden onset and progressive diplopia, photophobia, hyperacusis, and right upper eyelid ptosis. Of note is that the patient was nine weeks pregnant at the time, as a result of an in vitro fertilization. (Following three failed attempts at fertilization, this was the first successful pregnancy.)
The patient reported a several year history of intermittent headaches that had been presumptively diagnosed and treated as "tension headaches." Two months prior to presentation her symptoms began to occur more frequently and severely, and one week prior to presentation she experienced "the worst headache of her life," which prompted a visit to the emergency room of an outside institution.
C.T. scan obtained at that time revealed the presence of a large sellar lesion invading the sphenoid sinus and right cavernous sinus. Due to the status of the patient's pregnancy, however, definitive intervention was deferred until after delivery. Careful observation was planned until that time.
Our physical examination was unremarkable except for a moderate amount of distress, right upper eyelid ptosis, and central scotoma of the right visual field. The cranial nerves were otherwise intact.
We obtained an M.R.I. which confirmed the presence of an intra and suprasellar mass, as described above, with areas of hemorrhage within it.
The patient was brought to surgery the following morning after consultation with our endocrinology and perinatology services. Perioperative monitoring of the fetus was coordinated with the latter. A fully endoscopic transnasal transsphenoidal resection of the tumor was performed.
Operative findings included a sphenoid sinus filled with tumor, a sella turcica occupied by tumor and normal gland, and invasion of tumor into the right cavernous sinus. Zero- and thirty degree endoscopes allowed visualization of these structures, as well as the carotid prominences, hypophyseal stalk, and right optic nerve. All identified tumor was removed with the use of microsurgical instruments, including gross tumor fragments from within the cavernous sinus. Pathological analysis yielded a diagnosis of adenoma that stained positively for growth hormone and prolactin.
The patient had an uneventful recovery, remaining in the surgical intensive care unit for 24 hours after surgery and in the hospital for an additional 48 hours prior to discharge. There were no perioperative obstetrical complications. Currently both mother and child are doing well as they enter the third trimester.
The benefits of a minimally invasive procedure for operating on pituitary lesions is highlighted in this case. The urgent status of the patient's problem, within the context of a guarded pregnancy, underscored the inherent desire to effect as little morbidity as possible. The endoscopic approach allowed us to perform an effective, safe, and definitive procedure while providing the patient with as brief an operative time and as comfortable a recovery as possible.
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