Incidence and risk factors associated with reoperation for sellar hematoma following endoscopic transsphenoidal pituitary surgery

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OBJECTIVE

Postoperative sellar hematoma is an uncommon complication of endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma that often requires emergency surgical evacuation. Sellar hematomas can cause mass effect and compress parasellar structures, leading to clinically significant symptoms such as visual impairment and severe headache. The objective of this study was to determine the incidence and risk factors associated with reoperation for postoperative hematoma after EETS for pituitary adenoma.

METHODS

The authors reviewed a prospectively acquired database of EETS for pituitary adenoma over 13 years at Weill Cornell Medicine, NewYork-Presbyterian Hospital and identified cases that required reoperation for confirmed hematoma. They also reviewed clinical and radiographic data of a consecutive series of patients undergoing EETS for pituitary adenoma who did not have postoperative hematoma, which served as the control group. Demographic data and risk factors were compared between the groups using univariate and multivariate analyses via binary logistic regression.

RESULTS

Among a cohort of 583 patients undergoing EETS for pituitary adenoma, 9 patients (1.5%) required operation for sellar hematoma evacuation. All 9 patients with reoperation for sellar hematoma presented with worsening in their vision, and severe headache was present in 67%. New postoperative endocrine dysfunction developed in 78%. Clot evacuation improved vision in 88%. The mean time to hematoma evacuation was 4.5 days. The median length of stay for patients with sellar hematoma was 8 days (range 4–210 days) compared with a median length of stay of 3 days (range 1–32 days) for the control patients (p < 0.005). Significant risk factors in univariate analysis were tumor diameter ≥ 30 mm (p < 0.005), suprasellar extension (p < 0.005), tumor volume (p < 0.005), cavernous sinus invasion (p < 0.05), gonadotroph histology (p < 0.05), antiplatelet use (p < 0.05), and elevated BMI (p < 0.05). On multivariate analysis, tumor diameter ≥ 30 mm (OR 4.555, CI 1.30–28.90; p < 0.05) and suprasellar extension (OR 1.048, CI 1.01–1.10; p < 0.05) were found to be the only independent predictors of sellar hematoma. The incidence of hematoma in tumors ≥ 30 mm was 5% (7/139).

CONCLUSIONS

Postoperative sellar hematoma requiring reoperation is a rare phenomenon after transsphenoidal surgery, often presenting with visual loss and headache. Clot evacuation results in improvement in vision, but long-term endocrinopathy often ensues. Tumor diameter ≥ 30 mm and suprasellar extent are the most reliable risk factors. Close postoperative scrutiny should be given to patients at high risk.

ABBREVIATIONS EETS = endonasal endoscopic transsphenoidal surgery; GH = growth hormone; GTR = gross-total resection; STR = subtotal resection.

Article Information

Correspondence Theodore H. Schwartz: Weill Cornell Medicine, New York, NY. schwarh@med.cornell.edu.

INCLUDE WHEN CITING Published online August 23, 2019; DOI: 10.3171/2019.6.JNS191169.

Disclosures Dr. Schwartz: consultant for RPW Technology, Integra, and Fleur Desbx; investor in Mivi Neuroscience and Serenity Medical Inc.; and ownership in Neurotechnology Investors LLC.

© AANS, except where prohibited by US copyright law.

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References

  • 1

    Arafah BMPrunty DYbarra JHlavin MLSelman WR: The dominant role of increased intrasellar pressure in the pathogenesis of hypopituitarism, hyperprolactinemia, and headaches in patients with pituitary adenomas. J Clin Endocrinol Metab 85:178917932000

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Atkinson JLNippoldt TBKoeller KK: Reoperation for sella haematoma after pituitary surgery. Clin Endocrinol (Oxf) 68:4134152008

  • 3

    Barzaghi LRLosa MGiovanelli MMortini P: Complications of transsphenoidal surgery in patients with pituitary adenoma: experience at a single centre. Acta Neurochir (Wien) 149:8778862007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Cappabianca PCavallo LMColao Ade Divitiis E: Surgical complications associated with the endoscopic endonasal transsphenoidal approach for pituitary adenomas. J Neurosurg 97:2932982002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Cavallo LMSolari DTasiou AEsposito Fde Angelis MD’Enza AI: Endoscopic endonasal transsphenoidal removal of recurrent and regrowing pituitary adenomas: experience on a 59-patient series. World Neurosurg 80:3423502013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Chohan MOLevin AMSingh RZhou ZGreen CLKazam JJ: Three-dimensional volumetric measurements in defining endoscope-guided giant adenoma surgery outcomes. Pituitary 19:3113212016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Ciric IRagin ABaumgartner CPierce D: Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery 40:2252371997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Dallapiazza RFGrober YStarke RMLaws ER JrJane JA Jr: Long-term results of endonasal endoscopic transsphenoidal resection of nonfunctioning pituitary macroadenomas. Neurosurgery 76:42532015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Dehdashti ARGanna AKarabatsou KGentili F: Pure endoscopic endonasal approach for pituitary adenomas: early surgical results in 200 patients and comparison with previous microsurgical series. Neurosurgery 62:100610172008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    El-Asmar NEl-Sibai KAl-Aridi RSelman WRArafah BM: Postoperative sellar hematoma after pituitary surgery: clinical and biochemical characteristics. Eur J Endocrinol 174:5735822016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Esquenazi YEssayed WISingh HMauer EAhmed MChristos PJ: Endoscopic endonasal versus microscopic transsphenoidal surgery for recurrent and/or residual pituitary adenomas. World Neurosurg 101:1861952017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Gondim JAAlmeida JPAlbuquerque LASchops MGomes EFerraz T: Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 14:1741832011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Halvorsen HRamm-Pettersen JJosefsen RRønning PReinlie SMeling T: Surgical complications after transsphenoidal microscopic and endoscopic surgery for pituitary adenoma: a consecutive series of 506 procedures. Acta Neurochir (Wien) 156:4414492014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Jane JA JrLaws ER Jr: The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg 193:6516592001

  • 15

    Komotar RJStarke RMRaper DMAnand VKSchwartz TH: Endoscopic endonasal compared with microscopic transsphenoidal and open transcranial resection of giant pituitary adenomas. Pituitary 15:1501592012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Laws ER JrBarkhoudarian G: The transition from microscopic to endoscopic transsphenoidal surgery: the experience at Brigham and Women’s Hospital. World Neurosurg 82 (6 Suppl):S152S1542014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Leng LZBrown SAnand VKSchwartz TH: “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62 (5 Suppl 2):E342E3432008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Mortini PBarzaghi RLosa MBoari NGiovanelli M: Surgical treatment of giant pituitary adenomas: strategies and results in a series of 95 consecutive patients. Neurosurgery 60:99310042007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19

    Negm HMAl-Mahfoudh RPai MSingh HCohen SDhandapani S: Reoperative endoscopic endonasal surgery for residual or recurrent pituitary adenomas. J Neurosurg 127:3974082017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Nittby HRMaltese AStåhl N: Early postoperative haematomas in neurosurgery. Acta Neurochir (Wien) 158:8378462016

  • 21

    Patel KSKazam JTsiouris AJAnand VKSchwartz TH: Utility of early postoperative high-resolution volumetric magnetic resonance imaging after transsphenoidal pituitary tumor surgery. World Neurosurg 82:7777802014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Schaberg MRAnand VKSchwartz THCobb W: Microscopic versus endoscopic transnasal pituitary surgery. Curr Opin Otolaryngol Head Neck Surg 18:8142010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Singh HEssayed WICohen-Gadol AZada GSchwartz TH: Resection of pituitary tumors: endoscopic versus microscopic. J Neurooncol 130:3093172016

  • 24

    Tabaee AAnand VKBarrón YHiltzik DHBrown SMKacker A: Endoscopic pituitary surgery: a systematic review and meta-analysis. J Neurosurg 111:5455542009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Tabaee AAnand VKBrown SMLin JWSchwartz TH: Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 117:113311372007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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