Delayed symptomatic cerebral vasospasm following vestibular schwannoma resection: illustrative case

Paurush Pasricha Department of Neurosurgery and Gamma Knife Radiosurgery, P. D. Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India

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Alay V Khandhar Department of Neurosurgery and Gamma Knife Radiosurgery, P. D. Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India

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Basant K Misra Department of Neurosurgery and Gamma Knife Radiosurgery, P. D. Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India

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BACKGROUND

Symptomatic cerebral vasospasm following posterior fossa extraaxial tumor resection is a rare phenomenon, with only 13 cases previously reported in the literature. The condition appears similar to vasospasm following supratentorial tumor resection, intraaxial posterior fossa tumor resection, and aneurysmal subarachnoid hemorrhage (aSAH). The majority of patients were not evaluated for vasospasm prior to symptom onset, leading to a delay in diagnosis.

OBSERVATIONS

The authors present their experience in a 56-year-old female who developed delayed cerebral vasospasm after excision of a solid-cystic vestibular schwannoma. Routine postoperative brain computed tomography showed evidence of subarachnoid hemorrhage in the basal cisterns. She was discharged on the 9th postoperative day. On the 11th day after tumor excision, she developed left hemiparesis, dysarthria, and dysphagia and was readmitted. Angiography confirmed bilateral diffuse cerebral vasospasm. The patient responded to standard hyperdynamic therapy used for vasospasm secondary to aSAH.

LESSONS

Symptomatic distant cerebral vasospasm after posterior fossa extraaxial tumor excision is a rare but challenging complication with a very high morbidity rate in reported cases. A high index of suspicion is required for early diagnosis and prompt management for a favorable outcome.

ABBREVIATIONS

aSAH = aneurysmal subarachnoid hemorrhage; CSF = cerebrospinal fluid; CT = computed tomography; MCA = middle cerebral artery; MRC = Medical Research Council; MRI = magnetic resonance imaging; SAH = subarachnoid hemorrhage

BACKGROUND

Symptomatic cerebral vasospasm following posterior fossa extraaxial tumor resection is a rare phenomenon, with only 13 cases previously reported in the literature. The condition appears similar to vasospasm following supratentorial tumor resection, intraaxial posterior fossa tumor resection, and aneurysmal subarachnoid hemorrhage (aSAH). The majority of patients were not evaluated for vasospasm prior to symptom onset, leading to a delay in diagnosis.

OBSERVATIONS

The authors present their experience in a 56-year-old female who developed delayed cerebral vasospasm after excision of a solid-cystic vestibular schwannoma. Routine postoperative brain computed tomography showed evidence of subarachnoid hemorrhage in the basal cisterns. She was discharged on the 9th postoperative day. On the 11th day after tumor excision, she developed left hemiparesis, dysarthria, and dysphagia and was readmitted. Angiography confirmed bilateral diffuse cerebral vasospasm. The patient responded to standard hyperdynamic therapy used for vasospasm secondary to aSAH.

LESSONS

Symptomatic distant cerebral vasospasm after posterior fossa extraaxial tumor excision is a rare but challenging complication with a very high morbidity rate in reported cases. A high index of suspicion is required for early diagnosis and prompt management for a favorable outcome.

ABBREVIATIONS

aSAH = aneurysmal subarachnoid hemorrhage; CSF = cerebrospinal fluid; CT = computed tomography; MCA = middle cerebral artery; MRC = Medical Research Council; MRI = magnetic resonance imaging; SAH = subarachnoid hemorrhage

Vasospasm is a dreaded complication of subarachnoid hemorrhage (SAH), which is usually secondary to aneurysm bleeding.1 It is a rare presentation after tumor resection, especially after excision of a vestibular schwannoma, and only a handful of cases have presented with delayed symptomatic vasospasm after tumor resection. We reviewed the literature available on symptomatic vasospasm after tumor resection, especially posterior fossa extraaxial tumors, and were able to identify 13 such cases, including 5 cases of posterior fossa schwannoma.2,3 In this article, we describe our experience with an additional case, with the aim of discussing various theories of vasospasm following posterior fossa tumor excision as well as the treatment strategy that can be provided.

Illustrative Cases

First Admission

A 56-year-old female with an unremarkable medical history presented to us with a 5-year history of progressive right-sided hearing loss, right-ear tinnitus for 1.5 years, imbalance while walking, and headaches for 6 months. On examination, she had nonuseful hearing in her right ear and appendicular ataxia. Magnetic resonance imaging (MRI) of the brain with contrast revealed an approximately 4.2 × 4.6 × 3.5–cm right-sided giant vestibular schwannoma exhibiting solid and cystic components with a fluid-fluid level in the posterior part of the tumor, suggesting intratumoral hemorrhage. There was significant compression of the brainstem and fourth ventricle (Fig. 1).

FIG. 1
FIG. 1

Preoperative axial T2-weighted (A) and postcontrast (B) MRI showing heterogeneously enhancing, 4.2 × 4.6 × 3.5–cm, right cerebellopontine angle and internal auditory canal mass lesion with a fluid-fluid level seen in its posterior part, suggestive of a solid-cystic giant right vestibular schwannoma.

Surgery

With the patient placed in left lateral decubitus position, a right retrosigmoid craniotomy and near-total excision of the tumor were performed under continuous facial nerve monitoring. The tumor was soft and solid-cystic, and dark-brownish fluid (suspected to be old hemorrhagic fluid) was seen coming out of the cyst after decompression. There was some bleeding during decompression of the solid part of the tumor. The internal auditory canal was drilled, and the facial nerve was identified at the porus. A thin sliver of tumor stuck to the facial nerve was left behind just medial to the internal auditory meatus. No major intraoperative bleeding, vessel injury, or vascular manipulation occurred during the procedure. Total blood loss during the surgery was 400 ml.

Postoperative Course

After the operation, the patient developed right facial paresis (House-Brackmann grade 4) and was started on physiotherapy. She had a satisfactory neurological recovery. Routine computed tomography (CT) of the brain with contrast on postoperative day 2 showed near-complete resection of the tumor (Fig. 2A). The scan also showed SAH in the bilateral sylvian fissures and the perimesencephalic and interpeduncular cisterns (Fig. 2B and C). On the 6th postoperative day, she developed fever for 1 day, generalized weakness, and ataxia. She was started on antibiotics and discharged on the 9th postoperative day.

FIG. 2
FIG. 2

A: Postcontrast axial CT image showing near-complete excision of the tumor. B and C: Axial CT images showing SAH in the perimesencephalic and interpeduncular cisterns and the bilateral sylvian fissures.

Second Admission

Two days after the discharge, she again presented in the emergency department with sudden-onset left hemiparesis (Medical Research Council [MRC] grade 3/5), dysarthria, and dysphagia. Brain MRI showed acute nonhemorrhagic right middle cerebral artery (MCA) territory infarction involving the frontal lobe and part of the external capsule (Fig. 3A). Magnetic resonance angiography showed the attenuation of flow in the right MCA predominantly involving the superior division and proximal M1 segment of the left MCA and moderate narrowing of the terminal portion of the basilar artery (Fig. 3B). She was started on hyperdynamic therapy, tablet nimodipine, tablet aspirin, and tablet atorvastatin via nasogastric tube. Muscle physiotherapy, speech therapy, and swallowing therapy were instituted. CT scanning of the brain on the 27th postoperative day confirmed the disappearance of the previously seen SAH (Fig. 3C and D). The patient demonstrated gradual neurological improvement. At the 4-month follow-up, the patient had significant recovery from hemiparesis (MRC grade 4+/5) and was able to perform her daily activities without assistance (modified Rankin Scale score 1). Follow-up MRI of the brain showed an expected small residual tumor and resolution of the right frontal infarct (Fig. 4).

FIG. 3
FIG. 3

A: Diffusion-weighted MRI showing an acute nonhemorrhagic right frontal (MCA territory) infarct. B: Magnetic resonance angiography of the brain showing the attenuation of flow in the right MCA mainly in the superior segment (white arrows), proximal M1 segment of the left MCA (white arrow with black border), and terminal portion of the basilar artery (black arrow with white border). C and D: Brain CT scans on postoperative day 27 showing the complete disappearance of the previously seen SAH in the basal cisterns and in the bilateral sylvian fissures.

FIG. 4
FIG. 4

Axial T2-weighted (A) and postcontrast (B) MRI showing a small residual tumor in the right intracanalicular and cerebellopontine cistern. Axial diffusion-weighted image (C) showing resolution of the right frontal infarct.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Although common after aneurysmal subarachnoid hemorrhage (aSAH), cerebral vasospasm has been documented as a rare complication following intracranial tumor removal, with 40 cases found in a 2013 systematic analysis.4 Since then, more cases have been reported, and there has been an improvement in the understanding of this phenomenon.

Observations

Vasospasm after intraaxial tumor excision has always been reported as bilateral, distant, and diffuse, although it is rare after extraaxial tumor resection. Pituitary tumor and the sellar area are the most common respective pathology and location associated with cerebral vasospasm, and only 13 cases of symptomatic cerebral vasospasm have been detected following extraaxial posterior fossa tumor excision.2–4 Of 5 posterior fossa schwannomas, in only 1 case did the authors confirm intraoperative bleeding as a cause of distant cerebral vasospasm. Ours is the second case of distant vasospasm after posterior fossa schwannoma excision secondary to hemorrhage and the first case confirming evidence of SAH on postoperative imaging.3,5–8

Krayenbuehl et al.3 were the first to report a case of vasospasm following tumor resection, which occurred after the excision of a pituitary macroadenoma. Various theories have been proposed for this rare occurrence of vasospasm following tumor excision. The literature indicates the high arterial blood load in the subarachnoid space,9 hypothalamic dysfunction,10 and/or vascular injury or manipulation1 as the causative factors. Vascular encasement and manipulation are thought to be more pertinent to the excision of extraaxial tumors, and hypothalamic injury is thought to play a major role in the development of vasospasm after the removal of suprasellar and middle cranial fossa tumors.4 The release of arterial vasoactive blood products following hemorrhage in the subarachnoid space is thought to irritate local as well as distant vasculature.11 The direct mechanical trauma to the arterial wall during tumor resection can induce local artery vasoconstriction, which results in an intrinsic myogenic response, upregulated norepinephrine levels, or increased cerebrovascular reactivity to norepinephrine and serotonin.8 Young people have enhanced contractility and elasticity of their arterioles, which can make them more susceptible to direct mechanical stress. In fact, the incidence of symptomatic vasospasm is lower among patients with aSAH who are older.12 Studies have also implicated direct stimulation of the A2 nucleus or the release of vasoactive substances from the tumor bed,13–15 affecting the postganglionic trigeminal system, the A2 nucleus, and the median eminence, as a cause of cerebral vasospasm, particularly after pituitary tumor and ventral medullary tumor removal.16–18

Table 1 summarizes the clinical details of 5 reported cases of symptomatic cerebral vasospasm after the excision of posterior fossa schwannoma. Most patients with cerebral vasospasm after posterior fossa schwannoma excision were young, with 4 of 5 being younger than 40 years of age.3,5,7,8 However, as in our case, 1 patient with vestibular schwannoma excision was 69 years old, and the author also described the tumor as having a cystic component.6 Two cases were reported to have undergone a cerebrospinal fluid (CSF) diversion procedure before the tumor excision, and in 1 of the cases, the authors suggested a relative paucity of CSF in the cisterns as a predisposing factor for vasospasm.6,7 Other than the 5 cases of schwannoma, we identified 8 cases of posterior fossa extraaxial tumor excisions leading to cerebral vasospasms. Tumors in these cases included 4 meningiomas and 1 each of epidermoid cyst, medulloblastoma, chordoma, and chondrosarcoma.1,19–22 Of a total 13 cases of posterior fossa extraaxial tumors that led to cerebral vasospasm, perioperative hemorrhage or imaging confirmation of SAH was reported in only 4 cases.5,20,21 In the remaining 9 cases, although the presence of hemorrhage was not explicit, only 2 had evidence of a lack of hemorrhage. One case reported minor intraoperative bleeding,7 whereas the other presented postoperative MRI showing minimal hemorrhage.22 The latency between the day of tumor excision and vasospasm ranged from 3 to 14 days, resembling aSAH-related vasospasm. However, in 1 case of petroclival and cavernous meningioma, vasospasm was recorded on the 1st postoperative day, and the author mentioned major vessel encasement of the tumor causing vessel manipulation and vasospasm.1 Similarly, 1 patient had symptom onset at the 3rd day after surgery, in whom the direct mechanical trauma to the arterial wall during tumor resection was postulated as the cause.8

TABLE 1

Summary of cases with symptomatic cerebral vasospasm after excision of posterior fossa schwannomas

Authors & YearAge (yrs), SexLocation of SchwannomaCSF Diversion Procedure BeforeMax Diameter of Tumor (cm)Cystic Component in TumorOp PositionVascular Manipulation or Tumor Encasement of Vessels to Undergo VasospasmMassive Intraop Blood Loss or High Vascularity of TumorEvidence of SAH on Postop ImagingDay of Symptom OnsetSymptomsDay of Diagnosis of VasospasmVessels Involved in VasospasmTreatmentOutcome at Last FU (vs status before vasospasm)
Krayenbuehl, 1960339, MLt vestibularNANANANANANANANAAphasia & hemiplegia13ICANANA
de Almeida et al., 1985526, MRt vestibularNo5NALt lat decubitus/ park benchNoYesNo8Aphasia & hemiparesis14Lt ICA, ACA, MCANADisability (residual monoparesis)
LeRoux et al., 1991669, MLt vestibularYes3YesNANAYesNo7Confusion, ataxia, upward gaze palsy, INO, lt facial weakness7Bilat VA, BA, & rt ICAHHH therapy, nimodipineDisability (mild gait ataxia)
Afshari et al., 201479, FLt hypoglossalYesNANoNANoNoNo8Hemiparesis, lt facial weakness, drowsiness8Bilat ICA, MCA, & ACAHHH therapy, nimodipine, milrinone, noradrenaline infusionRecovery
Qi et al., 2015816, MLt ventral medulla oblongataNo2.5NoRt lat decubitusYesNoNo3Altered sensorium & fever3Bilat ICA & BAHHH therapy, decompressive craniectomyDisability (KPS 40)
Present case56, FRt vestibularNo4.6YesLt lat decubitusNoNoYes6Fever & ataxia followed by hemiparesis, dysphagia & dysarthria11Rt MCA, proximal M1 segment of lt MCA, distal BAHyperdynamic therapy, nimodipine, anticoagulantsDisability (residual hemiparesis)

ACA = anterior cerebral artery; BA = basilar artery; FU = follow-up; HHH therapy = hypertensive, hypervolemic, hemodilution therapy; ICA = internal carotid artery; INO = internuclear ophthalmoplegia; KPS = Karnofsky performance status; MCA = middle cerebral artery; NA = not available; VA = vertebral artery.

Our patient had a giant solid-cystic tumor with the release of the cyst contents during decompression, and there was indeed some bleeding during decompression of the tumor; total blood loss was 400 ml during surgery, and blood seeping into the subarachnoid space due to the lateral position would have been the cause of the documented evidence of postoperative SAH in the basal cisterns and sylvian fissures. The release of vasoactive materials from the tumor might have played a role, especially given the release of the cyst fluid that can disseminate in cisterns. Last, the presence of blood in the subarachnoid space after surgery seems to be the most likely causative factor of vasospasm. Prompt initiation of cerebral perfusion–directed hyperdynamic therapy can help in the reversal of vasospasm.

Lessons

Our case report and the existing literature indicated that arterial blood in the subarachnoid space can contribute to symptomatic vasospasm after extraaxial posterior fossa tumor removal. Similarities with vasospasm following aSAH, such as the presence and degree of bleeding prior to vasospasm and the duration of the initiation and distribution of vasospasm, may lend support to this theory. Recognizing this relationship may enhance efforts to reduce perioperative bleeding. In addition, routine techniques for the prediction and management of post-aSAH vasospasm may be used in select cases after tumor resection accompanied by large-volume perioperative bleeding and/or in cases with postoperative imaging evidence of SAH.

Author Contributions

Conception and design: all authors. Acquisition of data: Pasricha, Khandhar. Analysis and interpretation of data: Pasricha, Khandhar. Drafting the article: Pasricha, Khandhar. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Misra. Statistical analysis: Pasricha, Khandhar. Administrative/technical/material support: all authors. Study supervision: Misra.

References

  • 1

    Bejjani GK, Sekhar LN, Yost AM, Bank WO, Wright DC Vasospasm after cranial base tumor resection: pathogenesis, diagnosis, and therapy. Surg Neurol. 1999;52(6):577584.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Hiwase AD, Kalyanasundaram K, Bak VS, Laden SM, Ovenden CD, Wells AJ Symptomatic cerebral vasospasm following posterior fossa hemangioblastoma resection: illustrative case. J Neurosurg Case Lessons. 2022;3(13):CASE21492.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Krayenbuehl H A contribution to the problem of cerebral angiospastic insult. Article in German. Schweiz Med Wochenschr. 1960;90:961965.

  • 4

    Alotaibi NM, Lanzino G Cerebral vasospasm following tumor resection. J Neurointerv Surg. 2013;5(5):413418.

  • 5

    de Almeida GM, Bianco E, Souza AS Vasospasm after acoustic neuroma removal. Surg Neurol. 1985;23(1):3840.

  • 6

    LeRoux PD, Haglund MM, Mayberg MR, Winn HR Symptomatic cerebral vasospasm following tumor resection: report of two cases. Surg Neurol. 1991;36(1):2531.

  • 7

    Afshari FT, Fitzgerald JJ, Higgins JN, Garnett MR, Fernandes HM, Santarius T Diffuse cerebral vasospasm following resection of a hypoglossal schwannoma in a child. Br J Neurosurg. 2014;28(4):541543.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Qi J, Zhang L, Jia W, Zhang J, Wu Z Diffuse cerebral vasospasm after resection of schwannoma: a case report. Neuropsychiatr Dis Treat. 2015;11:317320.

  • 9

    Fisher CM, Kistler JP, Davis JM Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6(1):19.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Wilkins RH Hypothalamic dysfunction and intracranial arterial spasms. Surg Neurol. 1975;4(5):472480.

  • 11

    Allen GS, Gross CJ, French LA, Chou SN Cerebral arterial spasm. Part 5: in vitro contractile activity of vasoactive agents including human CSF on human basilar and anterior cerebral arteries. J Neurosurg. 1976;44(5):594600.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Torbey MT, Hauser TK, Bhardwaj A, et al. Effect of age on cerebral blood flow velocity and incidence of vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 2001;32(9):20052011.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Mawk JR Vasospasm after pituitary surgery. J Neurosurg. 1983;58(6):972.

  • 14

    Mawk JR, Ausman JI, Erickson DL, Maxwell RE Vasospasm following transcranial removal of large pituitary adenomas. Report of three cases. J Neurosurg. 1979;50(2):229232.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Wilson JL, Feild JR The production of intracranial vascular spasm by hypothalamic extract. J Neurosurg. 1974;40(4):473479.

  • 16

    Chang SD, Yap OW, Adler JR Jr. Symptomatic vasospasm after resection of a suprasellar pilocytic astrocytoma: case report and possible pathogenesis. Surg Neurol. 1999;51(5):521527.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Aoki N, Origitano TC, al-Mefty O Vasospasm after resection of skull base tumors. Acta Neurochir (Wien). 1995;132(1-3):5358.

  • 18

    Atalay B, Bolay H, Dalkara T, Soylemezoglu F, Oge K, Ozcan OE Transcorneal stimulation of trigeminal nerve afferents to increase cerebral blood flow in rats with cerebral vasospasm: a noninvasive method to activate the trigeminovascular reflex. J Neurosurg. 2002;97(5):11791183.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Aw D, Aldwaik MA, Taylor TR, Gaynor C Intracranial vasospasm with delayed ischaemic deficit following epidermoid cyst resection. Br J Radiol. 2010;83(991):e135e137.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Cervoni L, Salvati M, Santoro A Vasospasm following tumor removal: report of 5 cases. Ital J Neurol Sci. 1996;17(4):291294.

  • 21

    Pan J, Levitt MR, Ferreira M Jr, Sekhar LN Symptomatic cerebral vasospasm following resection of skull base tumors: case report and literature review. Clin Neurol Neurosurg. 2021;202:106482.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Rao VK, Haridas A, Nguyen TT, Lulla R, Wainwright MS, Goldstein JL Symptomatic cerebral vasospasm following resection of a medulloblastoma in a child. Neurocrit Care. 2013;18(1):8488.

    • PubMed
    • Search Google Scholar
    • Export Citation
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  • FIG. 1

    Preoperative axial T2-weighted (A) and postcontrast (B) MRI showing heterogeneously enhancing, 4.2 × 4.6 × 3.5–cm, right cerebellopontine angle and internal auditory canal mass lesion with a fluid-fluid level seen in its posterior part, suggestive of a solid-cystic giant right vestibular schwannoma.

  • FIG. 2

    A: Postcontrast axial CT image showing near-complete excision of the tumor. B and C: Axial CT images showing SAH in the perimesencephalic and interpeduncular cisterns and the bilateral sylvian fissures.

  • FIG. 3

    A: Diffusion-weighted MRI showing an acute nonhemorrhagic right frontal (MCA territory) infarct. B: Magnetic resonance angiography of the brain showing the attenuation of flow in the right MCA mainly in the superior segment (white arrows), proximal M1 segment of the left MCA (white arrow with black border), and terminal portion of the basilar artery (black arrow with white border). C and D: Brain CT scans on postoperative day 27 showing the complete disappearance of the previously seen SAH in the basal cisterns and in the bilateral sylvian fissures.

  • FIG. 4

    Axial T2-weighted (A) and postcontrast (B) MRI showing a small residual tumor in the right intracanalicular and cerebellopontine cistern. Axial diffusion-weighted image (C) showing resolution of the right frontal infarct.

  • 1

    Bejjani GK, Sekhar LN, Yost AM, Bank WO, Wright DC Vasospasm after cranial base tumor resection: pathogenesis, diagnosis, and therapy. Surg Neurol. 1999;52(6):577584.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Hiwase AD, Kalyanasundaram K, Bak VS, Laden SM, Ovenden CD, Wells AJ Symptomatic cerebral vasospasm following posterior fossa hemangioblastoma resection: illustrative case. J Neurosurg Case Lessons. 2022;3(13):CASE21492.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Krayenbuehl H A contribution to the problem of cerebral angiospastic insult. Article in German. Schweiz Med Wochenschr. 1960;90:961965.

  • 4

    Alotaibi NM, Lanzino G Cerebral vasospasm following tumor resection. J Neurointerv Surg. 2013;5(5):413418.

  • 5

    de Almeida GM, Bianco E, Souza AS Vasospasm after acoustic neuroma removal. Surg Neurol. 1985;23(1):3840.

  • 6

    LeRoux PD, Haglund MM, Mayberg MR, Winn HR Symptomatic cerebral vasospasm following tumor resection: report of two cases. Surg Neurol. 1991;36(1):2531.

  • 7

    Afshari FT, Fitzgerald JJ, Higgins JN, Garnett MR, Fernandes HM, Santarius T Diffuse cerebral vasospasm following resection of a hypoglossal schwannoma in a child. Br J Neurosurg. 2014;28(4):541543.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Qi J, Zhang L, Jia W, Zhang J, Wu Z Diffuse cerebral vasospasm after resection of schwannoma: a case report. Neuropsychiatr Dis Treat. 2015;11:317320.

  • 9

    Fisher CM, Kistler JP, Davis JM Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6(1):19.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Wilkins RH Hypothalamic dysfunction and intracranial arterial spasms. Surg Neurol. 1975;4(5):472480.

  • 11

    Allen GS, Gross CJ, French LA, Chou SN Cerebral arterial spasm. Part 5: in vitro contractile activity of vasoactive agents including human CSF on human basilar and anterior cerebral arteries. J Neurosurg. 1976;44(5):594600.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Torbey MT, Hauser TK, Bhardwaj A, et al. Effect of age on cerebral blood flow velocity and incidence of vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 2001;32(9):20052011.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Mawk JR Vasospasm after pituitary surgery. J Neurosurg. 1983;58(6):972.

  • 14

    Mawk JR, Ausman JI, Erickson DL, Maxwell RE Vasospasm following transcranial removal of large pituitary adenomas. Report of three cases. J Neurosurg. 1979;50(2):229232.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Wilson JL, Feild JR The production of intracranial vascular spasm by hypothalamic extract. J Neurosurg. 1974;40(4):473479.

  • 16

    Chang SD, Yap OW, Adler JR Jr. Symptomatic vasospasm after resection of a suprasellar pilocytic astrocytoma: case report and possible pathogenesis. Surg Neurol. 1999;51(5):521527.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Aoki N, Origitano TC, al-Mefty O Vasospasm after resection of skull base tumors. Acta Neurochir (Wien). 1995;132(1-3):5358.

  • 18

    Atalay B, Bolay H, Dalkara T, Soylemezoglu F, Oge K, Ozcan OE Transcorneal stimulation of trigeminal nerve afferents to increase cerebral blood flow in rats with cerebral vasospasm: a noninvasive method to activate the trigeminovascular reflex. J Neurosurg. 2002;97(5):11791183.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Aw D, Aldwaik MA, Taylor TR, Gaynor C Intracranial vasospasm with delayed ischaemic deficit following epidermoid cyst resection. Br J Radiol. 2010;83(991):e135e137.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Cervoni L, Salvati M, Santoro A Vasospasm following tumor removal: report of 5 cases. Ital J Neurol Sci. 1996;17(4):291294.

  • 21

    Pan J, Levitt MR, Ferreira M Jr, Sekhar LN Symptomatic cerebral vasospasm following resection of skull base tumors: case report and literature review. Clin Neurol Neurosurg. 2021;202:106482.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Rao VK, Haridas A, Nguyen TT, Lulla R, Wainwright MS, Goldstein JL Symptomatic cerebral vasospasm following resection of a medulloblastoma in a child. Neurocrit Care. 2013;18(1):8488.

    • PubMed
    • Search Google Scholar
    • Export Citation

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