Case Report
Posterior Reversible Encephalopathy Syndrome After Transsphenoidal Resection of
Pituitary Macroadenoma
Marcus Wong1, Sibi Rajendran1, Shruti Harish Bindiganavile3, Nita Bhat3, Andrew G. Lee2,4-10, David S. Baskin1,2
Key words
- CSF diversion
- Endoscopic endonasal
- Intracranial hypotension
- PRES
- Transsphenoidal
Abbreviations and Acronyms
CSF: Cerebrospinal fluid
MRI: Magnetic resonance imaging
PRES: Posterior reversible encephalopathy syndrome
SBP: Systolic blood pressure
TSS: Transsphenoidal surgery
From the 1Neurological Institute, Department of
Neurosurgery, Houston Methodist Hospital, Houston, Texas;
2
Kenneth R. Peak Brain and Pituitary Tumor Treatment
Center, Houston, Texas; 3Blanton Eye Institute, Department
of Ophthalmology, Houston Methodist Hospital, Houston,
Texas; 4Department of Ophthalmology, Weill Cornell
Medicine, New York, New York; 5Department of
Ophthalmology, Baylor College of Medicine, Houston, Texas;
6
Department of Ophthalmology, University of Texas Medical
Branch, Galveston, Texas; 7Department of Ophthalmology,
University of Texas MD Anderson Cancer Center, Houston,
Texas; 8Department of Ophthalmology, Texas A&M College
of Medicine, Bryan, Texas; 9Department of Ophthalmology,
University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
10
Department of Ophthalmology, University at Buffalo,
Buffalo, New York, USA
To whom correspondence should be addressed:
Marcus Wong, M.D.
[E-mail: mswong@houstonmethodist.org]
Citation: World Neurosurg. (2020) 142:171-175.
https://doi.org/10.1016/j.wneu.2020.06.136
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter Published by Elsevier Inc.
INTRODUCTION
Posterior reversible encephalopathy syn-
drome (PRES) is a well-described final
common pathway for a number of patho-
genic mechanisms affecting the blood-brain
barrier. PRES is typically characterized by
posterior location (e.g., occipital lobes), a
reversible neurologic deficit (due to vaso-
genic edema), and encephalopathy (e.g.,
headache, altered consciousness, and sei-
zures).1 Atypical PRES, however, may be
anterior rather than posterior in location,
WORLD NEUROSURGERY 142: 171-175, OCTOBER 2020
- BACKGROUND: Posterior reversible encephalopathy syndrome is manifested
by a reversible neurologic deficit such as vision loss, encephalopathy, and a
posterior location, typically the occipital lobes. It is commonly thought to be
related to acute, severe hypertension.
- CASE DESCRIPTION: A 51-year-old woman presented with visual loss for
several months, and a suprasellar mass was diagnosed. She underwent trans-
sphenoidal surgery, which was complicated by cerebrospinal fluid leak, and she
developed posterior reversible encephalopathy syndrome while undergoing
postoperative cerebrospinal fluid drainage via lumbar catheter. Her visual acuity
progressed to blindness, but blindness was reversed by discontinuation of
lumbar drainage, tight blood pressure control, and high-dose steroid drip.
- CONCLUSIONS:
To our knowledge, this is only the second case of posterior
reversible encephalopathy syndrome following transsphenoidal surgery to be
reported in the neurosurgical or ophthalmic English language literature.
may cause irreversible (due to cytotoxic CASE DESCRIPTION
edema) damage rather than being fully
A 51-year-old woman presented with visual
reversible), and may not include
loss for several months, and a suprasellar
encephalopathy. Though many drugs and
mass was diagnosed. Her past medical,
predisposing factors have been implicated,
surgical, social, and family history was
the most common risk factor for PRES
negative. She was taking no medications
development is acute, severe
and had no allergies. Her blood pressure
hypertension.2 Other associated conditions
before surgery was normal. Preoperative
include preeclampsia/eclampsia, sepsis,
MRI showed a 2.7 cm anteroposterior  2.5
autoimmune disease, chemotherapy, and
cm transverse  2.9 cm craniocaudal mass
solid-organ or bone marrow/stem cell
in the suprasellar region with displacement
transplantation.3 The diagnosis is made
and compression of the optic chiasm
clinically and is supported by magnetic
(Figure 1). Preoperative eye examination
resonance imaging (MRI) showing typical
showed normal visual acuity (20/20 in
white matter changes and diffusion-
both eyes) but a dense bitemporal
weighted imaging showing vasogenic
hemianopsia (Humphrey visual field 24-2)
(rather than cytotoxic) edema in the poste-
(Figure 2) with associated optic atrophy in
rior parietal and occipital lobes.4 Several
both eyes on examination and on optical
mechanisms have been proposed, but
coherence tomography.
ultimately the pathophysiologic basis
appears to be linked to failure of proper A periprocedural lumbar drain was
cerebral vascular autoregulation.5 PRES inserted before surgery. The patient was
following neurosurgical procedures is positioned in a park-bench position with
distinctly rare and has been reported only tumor and sellar localization performed
once previously after transsphenoidal with intraoperative navigation and fluo-
surgery (TSS). To our knowledge, this is roscopy. A radical subtotal excision was
only the second such case to be reported in achieved with good decompression of the
optic apparatus. A small intraoperative
the neurosurgical or ophthalmic English
language literature. CSF leak was noted at the base of the
www.journals.elsevier.com/world-neurosurgery 171
 CASE REPORT
MARCUS WONG ET AL. PRES AFTER TRANSSPHENOIDAL SURGERY

tumor capsule, which was sealed intra-

operatively, and a fat graft was placed.
Preoperative and intraoperative blood
pressure measurements were normal.
The immediate postoperative course
was uneventful. Notably there was dra-
matic improvement in her bitemporal
hemianopsia (Humphrey visual field 24-2)
(Figure 3). She was started on a
hydrocortisone taper and prophylactic
antibiotics for her lumbar drain, which
drained approximately 200 mL a day. On
postoperative day 4, her blood pressure
began to increase from her baseline
systolic blood pressure (SBP) of 120 mm
Hg to 160 mm Hg sustained over 24
hours, with a maximum of 180 mm Hg.
She had a concurrent headache that
progressed throughout the evening, and
by morning she began having quickly
declining vision to no light perception
bilaterally. Emergent computed
tomography and MRI revealed bilateral
occipital hypodensity with an associated
abnormal T2 fluid-attenuated inversion
recovery signal compatible with ongoing
edema (Figure 4). A new thin subdural
collection consistent with intracranial
hypotension was also noted. Notably no
sinus thrombosis, pituitary apoplexy, or
Figure 1. Preoperative imaging. (AeC) Contrast-enhanced T1-weighted magnetic resonance imaging
coronal (A), sagittal (B), and axial (C) views. (D) Sagittal computed tomography angiography shows the compression of the optic chiasm was seen.
pituitary adenoma with expansion of the sella turcica. She was transferred to the intensive
care unit for 5.4 mg/kg/hour methyl-
prednisolone drip and strict blood pres-
sure control to keep her SBP between 120
and 145 mm Hg using an antihyperten-
sive drip. The lumbar drain was clamped
and removed. Over the day, her vision
improved significantly, and she was able
to discern rough shapes. Blood pressure
control and steroid drip were maintained
for 3 days, and she was noted on formal
ophthalmologic examination to have
improved vision from counting fingers
(20/100 right eye, 20/200 left eye, to right
eye 20/70, left eye 20/60). The pupil ex-
amination was normal in both eyes, and
the remainder of the eye examination,
including the fundus examinations, was
normal in both eyes. By postoperative day
10 (intensive care unit day 6), she was
noted to have improved bitemporal
hemianopsia and vision good enough to
read and use her cellular phone. Sur-
veillance MRI revealed resolution of pre-
vious fluid-attenuated inversion recovery
Figure 2. Preoperative visual fields with classic dense bitemporal hemianopsia on Humphrey visual
signal and subdural collections. She was
fields.
discharged on postoperative day 14 on

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 CASE REPORT
MARCUS WONG ET AL. PRES AFTER TRANSSPHENOIDAL SURGERY

low-dose hydrocortisone and oral anti-

hypertensives. She was seen in both the
neurosurgery and the ophthalmology
clinic, and her postoperative bitemporal
hemianopsia had improved compared
with preoperative baseline, with some
residual field loss present (Figure 3). Her
visual acuity returned to preoperative 20/
50 in both eyes.

DISCUSSION
We present a case of PRES following
endoscopic endonasal transsphenoidal
resection of a pituitary tumor where the
patient developed worsening visual
disturbance and headache. Given that
Figure 3. Postoperative visual fields with bitemporal hemianopsia denser superiorly on Humphrey both visual changes and headache can be
visual fields. related to pituitary tumors and post-
operative complications of TSS (e.g.,
hemorrhage into the resection cavity,
apoplexy, edema), the immediate
concern was for those entities. Emergent
imaging should always be performed in
post-operative patients with new deficit,
and in our case immediate CT and MRI
were obtained. Our patient had classic
bitemporal hemianopsia before surgery,
but developed complete blindness
following onset of PRES after surgery.
Similarly, in the other case of PRES
following TSS in the literature, vision
decline in the form of new right hom-
onymous hemianopsia was observed.6 In
that case, there was no intraoperative
CSF leak and no lumbar drain used.
Neuro-ophthalmology consultation and
formal visual field testing was obtained
in our case, and we suggest the same for
all patients with PRES-associated visual
disturbances.
The current most accepted pathophysio-
logic basis of PRES involves a hyper-
perfusion injury model related to
hypertension.7 A sudden elevation in blood
pressure causes critical failure of cerebral
autoregulation. Arteriolar dilation and
endothelial dysfunction cause disruption of
the blood-brain barrier and thus the resul-
tant vasogenic edema that can be appreci-
ated on imaging. Though this theory seems
sufficient to explain PRES related to acute
hypertension, it fails to address the cases
Figure 4. (A) Emergent computed tomography coinciding with progressive vision loss reveals bilateral (estimated at 30%) of PRES not related to
occipital lobe hypodensity. (B) Magnetic resonance imaging T2 fluid-attenuated inversion recovery hypertension.1 The other competing
signal concerning for PRES in the same location as hypodensity. (C) Follow-up magnetic resonance hypothesis implicates hypotension as a
imaging reveals resolving T2 fluid-attenuated inversion recovery signal 6 days after initiation of blood
pressure control and steroids and removal of lumbar drainage.
cause, where decreased blood pressure
leads to reflexive vasoconstriction, cerebral

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MARCUS WONG ET AL.
ischemia, and ultimately vasogenic edema.
Another theory describes an immunologic
mechanism, where T-cell/endothelial cell
activation leads to trafficking of leukocytes,
cerebral vasoconstriction, hypoperfusion,
ischemia, and subsequent vasogenic
edema.8
Regardless of the underlying mecha-
nism, it remains unclear how recent
neurosurgical intervention plays a role in
development of PRES. Case reports of
PRES following neurosurgery come from
a wide variety of different procedures,
from cerebrovascular to neuro-oncologic
and beyond.9,10 Proximity of surgery to
the parietal and occipital lobes does not
play an obvious role, especially as
evidenced by cases of PRES following
pituitary surgery, including our own. In
our case, intracranial hypotension could
have precipitated PRES. As brain
perfusion is dependent on systemic
mean arterial pressure and intracranial
pressure, any increase in mean arterial
pressure or decrease in intracranial
pressure will result in a decrease in
brain perfusion in the setting of
autoregulation failure. Just as the
primary pathogenesis of PRES is
thought to be hyperperfusion secondary
to hypertension, hyperperfusion
secondary to intracranial hypotension
must also be considered. In our case,
prolonged intracranial hypotension from
CSF leak or its treatment, the lumbar
drain, may have made a large
contribution to the development of
PRES. The temporal relationship of
PRES development over 4 days of
lumbar drainage as well as the start of
improvement the day the drain was
removed adds weight to this theory as
well. There have been cases in the
literature that have hypothesized a
sudden decrease in intracranial pressure
as a possible link.11 In that article, the
authors described a patient with a
ruptured aneurysm who developed PRES
following successful clipping but
inadvertent overdrainage from the
ventricular drain.12 The same article
described another case in which a
patient with arachnoid cyst presenting
with obstructive hydrocephalus was
treated with cystoperitoneal shunt and
174 www.SCIENCEDIRECT.com
PRES AFTER TRANSSPHENOIDAL SURGERY
developed PRES following surgery
characterized by altered consciousness
and status epilepticus.
A final point remains in treatment of
PRES. While there remains much specu-
lation on the true mechanisms behind
PRES, nearly all studies support strict
blood pressure control in the treatment of
PRES once it has developed. In our case,
the patient was maintained on strict blood
pressure parameters (SBP between 120
and 145 mm Hg). She was treated with
intravenous nicardipine infusion when
SBP was e>145 mm Hg and with crystal-
loid fluid bolus <120 mm Hg. The result
was steady improvement in headache and
vision from day to day, with complete
resolution within 1 week and return to
better than baseline peripheral vision
(bitemporal hemianopsia in our case).
Though our patient did not experience
seizures related to PRES, the literature
supports the use of antiepileptic drugs
when applicable. Our patient was also
treated with high-dose corticosteroids,
which remains controversial in the litera-
ture. Some articles have demonstrated a
positive effect of steroids, especially in
patients with significant vasogenic edema,
but others have implicated steroids as a
cause of PRES.13,14 Though the literature
is less clear on this subject, our patient
improved while on steroids, and we
would to treat future patients with
steroids until more conclusive literature
becomes available.
CONCLUSIONS
PRES is a rare and serious neurologic
disease that may occur following
neurosurgical intervention among a wide
array of predisposing factors. We
describe the second reported case in the
literature of PRES following endoscopic
endonasal TSS of pituitary adenoma.
Our case is unique in the development
of PRES in the setting of intracranial
hypotension through CSF leak and
lumbar drainage. These symptoms
improved when the lumbar drain was
removed. Though pathophysiologic
mechanisms remain debated, the
consensus on treatment remains strict
blood pressure control, antiepileptic
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.06.136
CASE REPORT
drugs where appropriate, and serial im-
aging and neurologic examinations to
evaluate for resolution. Corticosteroids
remain controversial, but most reports
seem to demonstrate a positive effect,
especially with regard to vasogenic
edema. We report a favorable outcome
in our patient, which we owe to timely
diagnosis and medical management.
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MARCUS WONG ET AL. PRES AFTER TRANSSPHENOIDAL SURGERY

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Conflict of interest statement: This work was supported in
part by Donna and Kenneth Peak, the Kenneth R. Peak
Foundation, the John S. Dunn Foundation, the Taub
Foundation, the Blanche Green Fund of the Pauline Sterne
Wolff Memorial Foundation, the Kelly Kicking Cancer
Foundation, the Methodist Hospital Foundation, and the
Veralan Foundation.
Received 27 April 2020; accepted 17 June 2020
Citation: World Neurosurg. (2020) 142:171-175.
https://doi.org/10.1016/j.wneu.2020.06.136
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter Published by Elsevier Inc.

WORLD NEUROSURGERY 142: 171-175, OCTOBER 2020 www.journals.elsevier.com/world-neurosurgery 175