P204. Management of Acute Pituitary Apoplexy after Circulatory Arrest and Mechanical Aortic Valve Replacement: A Case Report
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
Philadelphia, PA
United States - Contact Me
Danielle Brown is a 3rd-year medical student at the University of Pennsylvania Perelman School of Medicine. She is interested in surgical care delivery, with prior research focused on improving disparities in surgical outcomes for patients with mental illness. Prior to medical school, she graduated from Duke University (c/o 2019) and worked at McKinsey & Company in Washington, D.C.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objectives: Pituitary apoplexy after cardiac surgery is a rare but described phenomenon that often requires operative intervention. We present a rare case of pituitary apoplexy following circulatory arrest and implantation of a mechanical aortic valve, requiring both post-operative anticoagulation and an acute neurosurgical resection.
Methods: A 54-year-old man with a bicuspid aortic valve with severe aortic stenosis and aortic dilation was recommended for mechanical root and ascending hemiarch replacement. During his preoperative evaluation, no neurologic symptoms were reported. The operation was an uncomplicated mechanical root and ascending hemiarch replacement performed under circulatory arrest with cooling to 18°C and retrograde cerebral perfusion. The procedure was uncomplicated, and the patient transferred to the ICU postoperatively.
Shortly after transfer, the patient was weaned off sedation and then noted to have ophthalmoplegia of the right eye and a fixed, dilated pupil. A stroke alert was called where the patient was evaluated by Neurology. An emergent non-contrast head CT and CT angiogram of the head and neck were negative for acute ischemic infarct or hemorrhage. However, a 3.0 cm mass was appreciated in the sellar/suprasellar cistern, with subsequent MRI demonstrating a cystic mass compressing the right optic nerve with extension into the right cavernous sinus.
ENT, Ophthalmology, Neurosurgery and Endocrinology were consulted. Initially, the patient trialed medical management with steroids and diuresis to address his cerebral edema. However, daily ophthalmic exams revealed worsening visual symptoms, prompting more urgent neurosurgical intervention. In the days leading up to his neurosurgical procedure, CT surgery and Neurosurgery worked together to balance the risks and benefits of anticoagulation for his recent mechanical valve with timing of operative intervention for his worsening intra-pituitary hemorrhage.
Results: The interdisciplinary team ultimately decided to initiate a heparin drip on post-operative day 4 and continue holding aspirin/coumadin. On post-operative day 9, he underwent a successful trans-sphenoidal neuro-endoscopic excision. Post-operatively, the patient developed intracranial hemorrhage in the operative bed, so anticoagulation continued to be held. Two days later, he developed a DVT in his left upper extremity, which prompted initiation of a heparin drip. Monitoring scans after heparin initiation demonstrated stability of the hemorrhage, and he was ultimately transitioned to warfarin on discharge. The patient recovered well and is currently living at home with some residual diplopia.
Conclusions: This case supports the idea that systemic anticoagulation can be temporarily held even in the acute period after mechanical valve replacement, when risk of a thromboembolic event is highest. It highlights the need for thoughtful multidisciplinary conversations when making decisions about anticoagulation and the optimal time for surgical intervention after intraoperative pituitary apoplexy. In this case, the patient's pituitary mass was successfully resected without major bleeding or thromboembolism complications.
Authors
Danielle Brown (1), Cecillia Lui (2), Yombe Fonkeu (3), Joseph Bavaria (2)
Institutions
(1) Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, (2) Hospital of the University of Pennsylvania, Philadelphia, PA, (3) Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA
Methods: A 54-year-old man with a bicuspid aortic valve with severe aortic stenosis and aortic dilation was recommended for mechanical root and ascending hemiarch replacement. During his preoperative evaluation, no neurologic symptoms were reported. The operation was an uncomplicated mechanical root and ascending hemiarch replacement performed under circulatory arrest with cooling to 18°C and retrograde cerebral perfusion. The procedure was uncomplicated, and the patient transferred to the ICU postoperatively.
Shortly after transfer, the patient was weaned off sedation and then noted to have ophthalmoplegia of the right eye and a fixed, dilated pupil. A stroke alert was called where the patient was evaluated by Neurology. An emergent non-contrast head CT and CT angiogram of the head and neck were negative for acute ischemic infarct or hemorrhage. However, a 3.0 cm mass was appreciated in the sellar/suprasellar cistern, with subsequent MRI demonstrating a cystic mass compressing the right optic nerve with extension into the right cavernous sinus.
ENT, Ophthalmology, Neurosurgery and Endocrinology were consulted. Initially, the patient trialed medical management with steroids and diuresis to address his cerebral edema. However, daily ophthalmic exams revealed worsening visual symptoms, prompting more urgent neurosurgical intervention. In the days leading up to his neurosurgical procedure, CT surgery and Neurosurgery worked together to balance the risks and benefits of anticoagulation for his recent mechanical valve with timing of operative intervention for his worsening intra-pituitary hemorrhage.
Results: The interdisciplinary team ultimately decided to initiate a heparin drip on post-operative day 4 and continue holding aspirin/coumadin. On post-operative day 9, he underwent a successful trans-sphenoidal neuro-endoscopic excision. Post-operatively, the patient developed intracranial hemorrhage in the operative bed, so anticoagulation continued to be held. Two days later, he developed a DVT in his left upper extremity, which prompted initiation of a heparin drip. Monitoring scans after heparin initiation demonstrated stability of the hemorrhage, and he was ultimately transitioned to warfarin on discharge. The patient recovered well and is currently living at home with some residual diplopia.
Conclusions: This case supports the idea that systemic anticoagulation can be temporarily held even in the acute period after mechanical valve replacement, when risk of a thromboembolic event is highest. It highlights the need for thoughtful multidisciplinary conversations when making decisions about anticoagulation and the optimal time for surgical intervention after intraoperative pituitary apoplexy. In this case, the patient's pituitary mass was successfully resected without major bleeding or thromboembolism complications.
Authors
Danielle Brown (1), Cecillia Lui (2), Yombe Fonkeu (3), Joseph Bavaria (2)
Institutions
(1) Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, (2) Hospital of the University of Pennsylvania, Philadelphia, PA, (3) Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA
Presentation Duration
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