title: Transcranial Evacuation of Atypical Progressive Supradiaphragmatic Hematoma After Transsphenoidal Complete Resection of Pituitary Adenoma.
abstract: OBJECTIVE
  Supradiaphragmatic hematoma is a type of hematoma that occurs after transsphenoidal (TS) resection of pituitary adenoma and requires special management.
  
  
  METHODS
  Two patients had symptomatic supradiaphragmatic hematomas after total TS resection of pituitary adenomas in the absence of vascular anomalies. Both patients also had hydrocephalus at the time of diagnosis of the hematoma. The initial endoscopic endonasal inspection showed no subdiaphragmatic bleeding. The hematoma was evacuated via a frontolateral approach after insertion of an external ventricular drain (EVD).
  
  
  RESULTS
  The supradiaphragmatic hematoma could be clinically and radiologically distinguished. It presented early with visual deterioration without headache. The patients developed hydrocephalus, which was associated with deterioration of level of consciousness. Radiologically, the hematoma filled the suprasellar space and was associated with the extension of bleeding in the basal cisterns. Recovery was good in both patients. There were no permanent neurologic deficits. The EVD was removed in both patients. One patient required a ventriculoperitoneal shunt because of delayed hydrocephalus.
  
  
  CONCLUSIONS
  Supradiaphragmatic hematoma can be clinically and radiologically distinguished from other types of hematoma occurring after TS resection of pituitary adenoma. Transcranial surgery should be performed to manage supradiaphragmatic hematoma, when symptomatic. Insertion of an EVD at the time of evacuation is mandatory to relax the brain and to alleviate the hydrocephalus.
authors.affiliation: International Neuroscience Institute, Hannover, Germany. Electronic address: drhussamm@yahoo.com.
authors.forename: Hussam
authors.initials: H
authors.lastname: Metwali
authors.affiliation: International Neuroscience Institute, Hannover, Germany.
authors.forename: Rudolf
authors.initials: R
authors.lastname: Fahlbusch
mesh_terms: D000236:Adenoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D004322:Drainage / Q000379:methods; D005260:Female; D006406:Hematoma / Q000209:etiology / Q000601:surgery*; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000601:surgery; D020300:Intracranial Hemorrhages / Q000209:etiology / Q000601:surgery*; D008297:Male; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods; D019635:Neurosurgical Procedures / Q000009:adverse effects; D010911:Pituitary Neoplasms / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D016896:Treatment Outcome
keywords: Complications; Hematoma; Microsurgery; Outcome; Pituitary adenoma; Supradiaphragmatic; Suprasellar