LETTER TO EDITOR
Year : 2017 | Volume
: 6 | Issue : 3 | Page : 197--198
Acute hemodynamic disturbances during pituitary surgery
Surya Kumar Dube1, Rupali Pattanaik2, Devika Agarwal1, Gyaninder P Singh1,
1 Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
Surya Kumar Dube
Department of Neuroanaesthesiology, 7th Floor C N Centre, All India Institute of Medical Sciences, New Delhi - 110 029
|How to cite this article:|
Dube SK, Pattanaik R, Agarwal D, Singh GP. Acute hemodynamic disturbances during pituitary surgery.Int J Health Allied Sci 2017;6:197-198
|How to cite this URL:|
Dube SK, Pattanaik R, Agarwal D, Singh GP. Acute hemodynamic disturbances during pituitary surgery. Int J Health Allied Sci [serial online] 2017 [cited 2020 Feb 21 ];6:197-198
Available from: http://www.ijhas.in/text.asp?2017/6/3/197/212598
Surgical resection of pituitary adenoma can have hemodynamic disturbances intraoperatively due to the manipulation of structures around pituitary fossa or injury to major vessels lying in the close vicinity. We report a case of acute hemodynamic disturbances that occurred due to injury to an internal carotid artery (ICA) and measures taken during its management.
A 43 years 62 kg male was diagnosed to have nonfunctional pituitary macroadenoma and was scheduled for transnasal trans-sphenoid endoscopic resection of pituitary adenoma. His primary complaint was diminished visual acuity and headache. He did not have any cardio-respiratory abnormality, his systemic examination and routine investigations were normal. Intraoperatively, following initial 1 h of stable hemodynamics, during resection of pituitary tumor, the patient sustained left sided ICA injury resulting in sudden hypotension and tachycardia which responded to rapid infusion of crystalloid, blood and blood products.
Meanwhile, all attempts to secure the bleeding vessel failed and the surgical team decided for balloon tamponade of the bleeding site. An 18 French size (Fr) Foleys catheter was inserted into the surgical site and was inflated rapidly. Immediately, after this maneuver patient's invasive blood pressure increased to 187/121 mmHg and heart rate dropped to 20 beats/min (bpm) followed by asystole. The Foleys catheter was deflated quickly, and within few seconds the heart rate increased to 106 bpm, and the blood pressure dropped to 103/61 mmHg. The Foleys catheter was again inflated gradually, and no cardiovascular disturbance was observed. The patient was subsequently shifted to the neuroradiological suit for endovascular intervention.
The possible causes of sudden hemodynamic change in pituitary surgery are inadequate anaesthesia and/or analgesia, surgical manipulation of the hypothalamic area, sudden blood loss, stimulation of any branch of the trigeminal nerve, and acute hydrocephalus. In our case, there were no signs of inadequate anaesthesia/analgesia, and neither the balloon inflation nor the surgical approach involved hypothalamic area manipulation. Acute hydrocephalus can cause hemodynamic disturbance through Cushing's response but was unlikely in our case as the Cushing's response after acute hydrocephalus will not be so sudden to appear and disappear after inflation and deflation of the catheter balloon. Moreover, the similar hemodynamic response was not observed on gradual inflation of catheter balloon subsequently. Hence, the most probable cause of sudden bradycardia and hypertension in our case was due to a trigemino cardiac reflex (TCR).
Stimulation of divisions of the trigeminal nerve in the lateral wall of cavernous sinus can cause hemodynamic disturbance due to TCR. Sudden bradycardia, hypotension, apnea, and gastric hypermobility are manifestations of the TCR. There are two forms of TCR (i.e., peripheral and central) described in the literature and bradycardia is common to both., However, peripheral TCR (triggered through branches of trigeminal nerve) can manifest as hypertension as compared to hypotension in central TCR (triggered through central divisions of the trigeminal nerve including Gasserian ganglion). The nature of the stimulus is an important risk factor in inducing the TCR and abrupt and sustained stimulus is more reflexogenic than smooth and gentle stimulus. Foley catheter was used to provide tamponade in our case as it is often used for obtaining vascular control in patients with exsanguinating hemorrhage. However, sudden inflation of the balloon in the vicinity of cavernous sinus leads to sudden severe hemodynamic alteration secondary to TCR. So, we suggest a slow and gradual inflation of Foley catheter balloon in proximity to cavernous sinus to avoid sudden and life-threatening hemodynamic alteration.
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