Synchronous Deep White-Matter Haemorrhages after Endoscopic Transsphenoidal Pituitary Macroadenoma Resection: Case Report and Literature Review

Résumé

Background: Intracranial haemorrhagic complications post endoscopic transsphenoidal surgery (TSS) are rare, and remote intracerebral haemorrhage (RICH) is an exceptionally infrequent occurrence. Furthermore, disseminated haemorrhages within the deep midline white matter are remarkably uncommon. We report a case of a patient who developed synchronous, multifocal disseminated haemorrhages following endoscopic partial resection of a massive pituitary macroadenoma. Case summary: A 75-year-old woman with a massive sellar–suprasellar pituitary macroadenoma compressing both the optic nerves and the chiasm, underwent endoscopic endonasal tumour debulking, followed by autologous skull base reconstruction. She had normal vital signs and was neurologically stable immediately post-operative but later developed acute left sided hemiparesis and a marked decline in consciousness approximately 30 hours post-operatively. Investigations:  Neuroimaging (30 hours post-operatively) revealed disseminated haemorrhages within the deep white matter and the cerebellum, along with small cerebral cortical infarcts, reflecting the multifocal nature of the injury. Cerebrospinal fluid (CSF) analysis post-deterioration showed markedly elevated protein (1,424 mg/dL; measured by spectrophotometry), a white cell count of 84 cells/µL (80% polymorphs), and normal glucose. Opening pressures were documented as normal. Management: The patient received supportive neurocritical care, scheduled lumbar drainage for CSF rhinorrhoea (which started on the fourth day after surgery), and broad-spectrum antibiotics. Outcome: Despite maximal therapy, the patient’s condition progressed to brain death, confirmed on post-operative day 10. Conclusion: Deep white matter disseminated haemorrhages after TSS are exceptionally rare. Potential etiologies include cerebral vasospasm, venous congestion secondary to dysregulated CSF dynamics, and microembolic events. This case highlights the importance of timely post-operative neuroimaging in any patient demonstrating neurological deterioration following TSS, with recognition of this imaging pattern as a potential complication.