Postoperative hemorrhages in vestibular schwannoma surgery pontine hemorrhage. Clinical case report

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Abstract

Vestibular schwannoma (acoustic neuroma) is a benign tumor that develops from Schwann cells and can be life-threatening. Nowadays, surgical treatment is the method of choice in the management of patients with this type of tumor.

We present a clinical case report of 71 y.o. patient with vestibular schwannoma (Koos grade IV, Samii grade 4B) with severe compression of the pons and the left cerebellar hemisphere. Microsurgical removal of the tumor was performed via the retrosigmoid approach. Starting from postoperative day 1, signs of respiratory distress developed. Control multislice spiral computed tomography (MSCT) of the brain revealed the area of hemorrhage in the left regions of the pons. On postoperative day 24 the patient's condition rapidly worsened progressing to coma with pronounced arterial hypotonia and cardiac arrest.

Hemorrhage in the brain stem structures is a rare and life-threatening postoperative complication in vestibular schwannoma surgery. The incidence of postoperative hemorrhage is 2–11% of cases. Vascular complications are the leading cause of mortality. The key predisposing factors are older age, large and giant size of the tumor, tumor invasion into the pia mater of the brainstem, and vascularization of the tumor stroma. Comprehensive assessment of the tumor blood supply status, the state of the brainstem, intra- and postoperative clinical and neurophysiological monitoring, careful and thorough dissection of the tumor capsule and strict control of blood pressure in the postoperative period are the basis for the prevention of these complications.

About the authors

Pavel G. Rudenko

Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University; Regional Clinical Hospital, Krasnoyarsk

Author for correspondence.
Email: rpg30@rambler.ru
ORCID iD: 0000-0001-9390-3134

Cand. Sci. (Med.), Associate Professor, Department of traumatology, orthopedics, neurosurgery with a course of postgraduate education, Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University; neurosurgeon, Department of neurosurgery No. 1, Regional Clinical Hospital

Russian Federation, Krasnoyarsk; Krasnoyarsk

Pavel G. Shnyakin

Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University; Regional Clinical Hospital, Krasnoyarsk

Email: shnyakinpavel@mail.ru
ORCID iD: 0000-0001-6321-4557
ResearcherId: AAI-8384-2020

D. Sci. (Med.), Head, Department of traumatology, orthopedics and neurosurgery with a course of postgraduate education, Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University; Head, Regional Vascular Center, Regional Clinical Hospital

Russian Federation, Krasnoyarsk; Krasnoyarsk

Ilona E. Milyokhina

Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University

Email: eie-89@mail.ru
ORCID iD: 0000-0002-3275-614X

Cand. Sci. (Med.), Associate Professor, Department of traumatology, orthopedics, neurosurgery with a course of postgraduate education, Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University

Russian Federation, Krasnoyarsk

Irina S. Usatova

Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University; Regional Clinical Hospital, Krasnoyarsk

Email: irinausatova01@mail.ru
ORCID iD: 0000-0001-6813-8776

assistant of the Department of traumatology, orthopedics and neurosurgery with a course of postgraduate education, Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University

Russian Federation, Krasnoyarsk; Krasnoyarsk

Marvorid N. Fayzova

Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University

Email: marvoridin00@gmail.com
ORCID iD: 0000-0001-8738-6847

postgraduate student, Department of traumatology, orthopedics, neurosurgery and postgraduate course, Professor V.F. Voyno-Yasenetsky Krasnoyarsk State Medical University

Russian Federation, Krasnoyarsk

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Supplementary files

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2. Fig. 1. Preoperative brain MRI of the patient revealed a left cerebellopontine angle tumor with intense inhomogeneous accumulation of paramagnetic contrast agent. Lateral ventricles are dilated. Preoperative coronal and axial contrast-enhanced T1-weighted MR images.

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3. Fig. 2. Contrast-enhanced head MSCT on postoperative day 1. No contrast-enhancing areas observed. Hemorrhage site is detected in the left regions of the pons.

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4. Fig. 3. Head MSCT on postoperative day 5.

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5. Fig. 4. Preoperative axial contrast-enhanced head MSCT scan with a peritumoral hypodensity area.

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Copyright (c) 2024 Rudenko P.G., Shnyakin P.G., Milyokhina I.E., Usatova I.S., Fayzova M.N.

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