American Journal of Clinical Neurology and Neurosurgery

Vol. 1, No. 3, 2015, pp. 150-153

http://www.aiscience.org/journal/ajcnn

Chronic Subdural Haematoma Development

Following Transsphenoidal Surgery for Pituitary
Adenoma Apoplexy: An Incidental or Real
Association
Guru Dutta Satyarthee*, Ribhav Pasricha

Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India

Abstract
Occurrence of symptomatic chronic subdural haematoma (SDH) following transsphenoidal decompression of pituitary
adenoma, which needed surgical evacuation, is not reported. Author reports a case of symptomatic chronic subdural
haematoma observed in a series of 480-transsphenoidal surgery. A 52-year old female underwent transsphenoidal surgery for
pituitary adenoma. She developed cerebrospinal fluid (C. S. F) rhinorrhoea in the immediate post-operative period, which
responded to conservative therapy. She presented with severe headache and paresis of left lower limbs one month after
cessation of C. S. F. rhinorrhoea, which necessitated burr hole evacuation of chronic subdural haematoma following which,
noticed complete resolution of headache and limb paresis. Management of such cases and pertinent literature is reviewed
briefly.

Keywords
Pituitary Adenoma, Trans-Sphenoid Surgery, Chronic Subdural Haematoma, Management

Received: August 4, 2015 / Accepted: August 13, 2015 / Published online: November 11, 2015
@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license.
http://creativecommons.org/licenses/by-nc/4.0/

1. Introduction
Chronic subdural haematoma is common in elderly
population usually as a sequlae of minor had injury; rarely
chronic subdural haematoma can also develop following
neurosurgical procedures of shunt surgery, aneurysm clipping
and other intracranial tumor surgery. 1-5 However, a
symptomatic chronic subdural haematoma as complication of
pituitary adenoma approached through transsphenoidal
approach, to the best of knowledge of authors, is not reported
in the western literature. Authors report a 52- year- female
developing chronic subdural hematoma, one month following
transsphenoidal decompression surgery during follow-up
period.
2. Case-Illustration
A 52-year-old female admitted with complaint of progressive
diminution of vision for ten months. On examination, she
was conscious; the visual acuity was 6/36 in right eye and 6/
24 in left eye with bitemporal field defect. Fundi showed
bilateral primary optic atrophy. Rest of the neurological
examination was normal.
Contrast enhanced CT scan revealed large sellar tumor with
suprasellar extension. [Figure-1] MRI brain showed marked
expansion of sellar fossa, containing 4.7 x 4.1cm in size on
T1WI isointense with large areas of hyperintensity on both
T1 and T2WI suggesting subacute haemorrhage with
suprasellar extending into suprasellar cistern causing
distortion and displacement of optic chiasm. [Figure-2, 3] A1

* Corresponding author
E-mail address: duttaguru2002@yahoo.com (G. D. Satyarthee)
 American Journal of Clinical Neurology and Neurosurgery Vol. 1, No. 3, 2015, pp. 150-153
segment of both anterior cerebral arteries are draped on mass
with erosion of sellar floor with extension into sphenoid
sinus was observed. A transnasal transsphenoidal radical
excision with packing of sella with fat and fascia was
performed. She had intraoperative CSF leak. In the post-
operative period, she had improvement in vision. However,
she developed CS rhinorrhoea, which responded to
conservative therapy. She was discharged after seventh day
following Cessation of CSF rhinorrhoea. She reported to
emergency services, one month after surgery with
progressive headache and left sided hemiparesis; however
she had no associated history of current clear watery
discharge through nose or history of fever or associated neck
rigidity. Neurological examination revealed left side upper
motor neuron seventh cranial nerve paresis and left sided
hemiparesis, the rest of examination being essentially
normal. CT scan done after readmission revealed right
temporoparietal chronic subdural haematoma. [Figure-4].
She underwent burr whole evacuation of hematoma, which
was under high pressure. She noticed immediate relief in
headache and hemiparesis also improved over three days. A
repeat CT scan three months after burr-hole evacuation
surgery revealed complete disappearance of chronic subdural
haematoma with small residual pituitary adenoma.
Fig. 1. Contrast enhanced CT scan revealed giant pituitary adenoma, having
large sellar mass with suprasellar extension.
151
3. Discussion
Traumatic chronic subdural haematoma is usually noticed in
elderly age group within few weeks of minor head injury. The
chronic subdural haematoma can also develop following
various non-traumatic neurosurgical procedures. SDH
development is potentially devastating complication, reported
following shunt surgery in normal pressure hydrocephalus or
nontraumatic intracranial surgery, 2 following aneurysm
surgery, 3 encephalomyosynangiosis for Moya-Moya disease. 4
Tanaka et al 3 reported three cases of chronic subdural
haematoma development, which required surgical evacuation
following aneurysm surgery out of a total 147 cases. Koizumi
et al 5 also reported incidence of 1.8% following intracranial
surgery among 169 cases studied, three cases developed SDH,
out of which two were operated for tumour, and rest one had
combined aneurysm surgery and VP shunt. For management of
SDH, one case required burr hole evacuation and remaining
two cases were managed conservatively in view of
asymptomatic and responded well. Tanaka et al 6 reported a
case of chronic subdural haematoma following transsphenoidal
surgery, which was managed conservatively, as this was
asymptomatic. However, our case was symptomatic and
showing progressive worsening in neurological status and
necessitated urgent surgical evacuation of chronic subdural
haematoma.
Fig. 2. Preoperative MRI, T1WI sagittal section showing giant pituitary
adenoma, with isointense mass in sella with suprasellar and sphenoid sinus
extension with areas of hyperintensity suggesting pituitary apoplexy.
Cerebrospinal fluid rhinorrhoea following transsphenoidal
surgery is a potentially serious complication. The incidence
of postoperative CSF rhinorrhoea is up to 9.6%. The CSF
rhinorrhoea usually subsides with conservative therapy. The
persistence of CSF rhinorrhoea can predispose development
152 Guru Dutta Satyarthee and Ribhav Pasricha: Chronic Subdural Haematoma development Following Transsphenoidal
Surgery for Pituitary Adenoma Apoplexy: An Incidental or Real Association
of tension pneumocephalus, meningitis, seizure etc.11 A
constant vigilance is required to monitor earliest
manifestation of pneumocephalus and require prompt
planning for further management. Delayed development of or
recurrence of cerebrospinal fluid rhinorrhoea can mask the
clinical feature of SDH. 11
Subdural fluid collection is considered pre-existing condition
for chronic subdural haematoma formation after head injury. 5
However, subdural fluid collection is noted to progress to
chronic subdural haematoma. 3, 5 Subdural fluid collection in
the cranial cavity has been noted following neurosurgical
procedures for aneurysm surgery, brain tumour surgery. Even
spinal subdural haematoma is reported to occur following
intracranial surgery, including acoustic neuroma surgery. 8 The
reported incidence of conversion of subdural fluid collection
into frank chronic subdural haematoma in the nontraumatic
intracranial neurosurgical procedure 1.8-3.9% 3, 4, 5 Various
factors, which promotes postoperative subdural haematoma
formation are brain atrophy, ventriculomegaly, blood mixed
CSF in subdural space. 3, 5, 7
Fig 3. Preoperative MRI, T1WI coronal section showing giant pituitary
adenoma, with isointense mass in sella with suprasellar and sphenoid sinus
extension with areas of hyperintensity suggesting pituitary apoplexy.
Various postulates are proposed to define the mechanism of
chronic subdural haematoma formation following various
neurosurgical interventions. Komatsu et al 9 observed three
patients with chronic subdural haematoma among 1000 cases
of aneurysm surgery in pre-CT era. They postulated the
mixture of CSF and blood from suture line of dura mater in
subdural space. This fact was also experimentally supported
by Watanable et al. 10 Schmidt and Reinhardt 12 examined
duramater of 50 cases in which brain surgery or CSF
drainage were performed, noticed development of
neomembrane, which showed focal transition to the typical
pattern of hemorrhagic internal pachymeningitis, this
membrane could be responsible for recurrent bleed and
evolution of chronic subdural haematoma. Tanka et al further
stressed that subdural fluid collection can convert into
chronic subdural haematoma. 3 They further demonstrated
CT scan wise attenuation change from hypo density to
hyperdensity. Koizumi et al 5 reported in additions to
subdural fluid collection, preoperative ventricular dilation,
brain atrophy seem to promote chronic subdural haematoma
formation. Decompression of the intracranial space
occupying lesion with removal large amount of cerebral
parenchymal tissue or additional CSF drainage during the
surgery makes the cranial cavity vulnerable to formation of
subdural haematoma or fluid collection. Koizumi et al 5
reported artificial formation of large subdural space is
important adverse effect of surgical procedure, as brain
shrink by aspiration of CSF, by removal of tumour or brain
retraction during surgery. Large subdural spaces formed at
the time of dural closure so large subdural fluid is observed
in immediate postoperative period, and gradually volume
shrinks or very rarely convert into chronic subdural
haematoma. Large subdural space may also promote rupture
of bridging veins leading to development of chronic subdural
hematoma.
Fig. 4. NCCT head showing large right sided frontoparietal with small left
sided chronic subdural hematoma.
 American Journal of Clinical Neurology and Neurosurgery Vol. 1, No. 3, 2015, pp. 150-153
Lee and Hong 13 observed the communication between
subdural space and large CSF spaces such as cisterns and
ventricles is important and is supported by aneurysm surgery,
sellar tumour surgery. In the current case, opening of
suprasellar cistern and persistent drainage of CSF in
postoperative period might have resulted into formation of
large subdural space, in which persistent slow oozing of
blood or collection of blood from other sources, have
potentiated the process of chronic subdural haematoma
formation.
Fig. 5. Post-operative contrast enhanced MRI brain showing small residual
pituitary adenoma.
The clinical manifestations are obscure because of primary
lesion or other complications. The management of these
chronic subdural haematoma following neurosurgical
procedure is dependent on the clinical symptoms, progress of
symptoms, neurological deficit as well as the thickness and
mass effect. 11, 13, 14 Tanaka et al 3 reported good result
following surgical evacuation of chronic subdural hematoma.
However, there was only case reported in the literature, who
developed subdural hematoma following transsphenoidal
pituitary adenoma excision, was managed conservatively.
However, our case had marked neurological deficit with
progression of deficit, necessitated surgical evacuation.
4. Conclusion
Any patient after neurosurgical intervention including
transsphenoidal surgery report with focal deficit or feature of
increased intracranial pressure possibility of chronic subdural
hematoma though incidence is very rare should be suspected.
However, the management is dependent on many factors;
however, suitable selected patient may show dramatic
153
neurological recovery following surgical evacuation of
chronic subdural hematoma.
References
[1] Samuelson S, Long DM, Chou SN. Subdural haematomas a
complication of shunting procedures for normal pressure
hydrocephalus. J Neurosurg 1972; 37:548-551.
[2] Driesen W, Elies W. Epidural and subdural haematoma as a
complication of internal damage of cerebrospinal fluid in
hydrocephalus. Act Neurochir (Wien) 1974; 30: 85-93.
[3] Tanaka Y, Mizuno M, Kobayashi S, Sugita K. Subdural fluid
collection following craniotomy, Surg Neurol 1987; 27: 353-
356.
[4] Sonobe M, Takahashi S, Kubota Y, Shirane R. Chronic
subdural hematoma developing after EMS for moyamoya
disease( In Japanese) Neurol Surg 1982; 10 : 857-859.
[5] Koizumi H, Fukamachi A, Nuku H. Postoperative subdural
fluid collection in neurosurgery. Surg Neurol 1987: 27: 147-
153.
[6] Tanaka Y, Kobayashi S, Hongo Y, Tada T .Chronic subdural
haematoma after transsphenoidal surgery. J Clin Neurosci
2002; 9: 323-325.
[7] Takahashi Y. pathogenic consideration on chronic subdural
haematoma after intracranial surgery for nontraumatic lesions.
Neurol Med Chir 987; 27: 1080-1086.
[8] Marx SV, Roberson DW, Coates G, langman AW. Spinal
subdural hematoma after resection of an acoustic neuroma.
Otolaryngol Head Neck Surg 1999; 120: 540-542.
[9] Komatsu S, Takaku A, Hori S. Three cases of chronic subdural
hematoma developing after direct aneurysm surgery, Neurol
Surg (Tokyo) 1977; 5; 273-1277.
[10] Watanable S, Schemata H, Ishi S. Production of clinical form
of chronic subdural haematoma in experimental animals. J
Neurosurg 1972; 37: 552-56.
[11] Satyarthee GD, Mahapatra AK. Tension pneumocephalus
following transsphenoidal surgery for pituitary adenoma -
report of two cases. J Cli Nreurosci 2003, 10: 495-497.
[12] Schmidt H, Reinhardt B. verandrungender Dura mater bei
hirnoperrierten, Ein Beitrag zur Frage Pachymeningitis
haemorrhageica interna und Trauma. Arch Psychiatr Nervenkr
1968; 211: 73-87.
[13] Lee JI, Hong SC. Spinal subdural haemtoma as a complication
of cranial surgery: case report. Acta Neurochir (Wien) 2003;
45: 41-415. \
[14] Raheja A, Satyarthee GD, Mahapatra AK. Chronic Subdural
Hematoma development in Accelerated phase of Chronic
Myeloid Leukaemia presenting with seizure and rapid
progression course with fatal outcome Romanian
Neurosurgery 2015; 29(2): 199202.