PMC10408626_01
Preoperative magnetic resonance images. (a) Atrophic change observed in the cerebrum and cerebellum. Cerebral superficial siderosis in the bilateral frontal lobes and cerebellar hemispheres, and hemorrhagic change in the tumor were also identified. (b) The tumor in the sella turcica extends close to the brain stem (a: T2 star-weighted images, and b: T1-weighted gadolinium-enhanced images).
SNI-14-256-g001.jpg
PMC10408626_01_SNI-14-256-g001.jpg
F1
The cerebrum and cerebellum were atrophic and superficial cerebral siderosis was confirmed in both hemispheres [Figure 1].
Intraoperative findings under neuroendoscope (a-c, d: under a neuroendoscope angled at 30 , e: under a neuroendoscope angled at 0 ). (a) Intratumoral hematoma is observed intraoperatively. The pituitary gland is compressed laterally by the tumor. (b) The pituitary gland and its stalk are preserved intraoperatively. (c-e) After the removal of the tumor in the sella turcica and posterior cranial fossa, the vascular and nerve structures are observed. Intraoperatively, they were preserved. Hemosiderin (asterisk) attaches to the brain surface. The left oculomotor nerve (dagger) is also identified. ACA: Anterior cerebral artery, BA: Basilar artery, ICA: Internal carotid artery, Lt: Left, MCA: Middle cerebral artery, PCA: Posterior cerebral artery, PG: Pituitary gland, Rt: Right, SCA: Superior cerebellar artery, SHA: Superior hypophyseal artery.
SNI-14-256-g002.jpg
PMC10408626_01_SNI-14-256-g002.jpg
F2
A dural incision was made and the tumor containing the acute and chronic hematomas was exposed [Figure 2a]. To preserve the pituitary stalk and gland [Figure 2b], the tumor was removed along the margin between the tumor and the arachnoid. Hemosiderin was observed on the cerebral surface [Figures 2c-e].
Postoperative radiological images. (a) Computed tomography images on a postoperative day 1 show large pneumocephalus and diffuse ischemic lesions in the bilateral insulae and cerebral cortices (white arrows), (b and c) Acute ischemic lesions in the insula, temporal, and frontal cortices are disclosed bilaterally (white arrow heads). Subarachnoid hemorrhage is not observed. (b) diffusion-weighted images, and (c) fluid-attenuated inversion recovery images.
SNI-14-256-g003.jpg
PMC10408626_01_SNI-14-256-g003.jpg
F3
Postoperative CT imaging on postoperative day 1 showed pneumocephalus and low-density areas in the bilateral insular and frontotemporal cortices, with no intracranial hemorrhage [Figure 3a]. MRA examination was performed to identify the cause of the postoperative low-density areas. MRI and MRA revealed acute ischemic lesions in the left thalamus, bilateral insulae, caudate nuclei, and temporal and frontal cortices [Figures 3b and c], with diffuse vasospasm in the bilateral middle cerebral arteries which was not observed preoperatively.
Pre and postoperative magnetic resonance angiography. The intracranial main vessel trunk is clearly visualized on preoperative magnetic resonance angiography (a). However, diffuse spastic changes are observed bilaterally in the middle cerebral artery (b).
SNI-14-256-g004.jpg
PMC10408626_01_SNI-14-256-g004.jpg
F4
The vasospasm was identified also in the distal middle cerebral artery [Figure 4].