Journal of Neuro-Ophthalmology, March 2004, Volume 24, Issue 1

Pituitary Apoplexy Occurring During Large Volume Liposuction Surgery

A 50-year-old woman developed headache and right-sided ophthalmoplegia upon awakening from general anesthesia after liposuction surgery on her abdomen, hips, and thighs. Neuroimaging showed hemorrhage within a previously undiagnosed pituitary adenoma. The confirmatory surgical specimen contained areas of gross infarction and hemorrhage. The anesthesia record revealed intraoperative reduction of systolic blood pressure to 90 mm Hg for 30 minutes from a baseline of 120 mm Hg. This first reported case of pituitary apoplexy during liposuction surgery probably resulted from intraoperative hypotension attributed to a combination of general anesthesia, the use of subcutaneous lidocaine, sequestration of plasma in injured tissues, and blood loss.

ORIGINAL CONTRIBUTION Pituitary Apoplexy Occurring During Large Volume Liposuction Surgery Amir Cohen, MD, MBA, Kamal Kishore, MD, Leo Wolansky, MD, and Larry Frohman, MD Abstract: A 50- year- old woman developed headache and right- sided ophthalmoplegia upon awakening from general anesthesia after liposuction surgery on her abdomen, hips, and thighs. Neuroimaging showed hemorrhage within a previously undiagnosed pituitary adenoma. The confirma­tory surgical specimen contained areas of gross infarction and hemorrhage. The anesthesia record revealed intraop­erative reduction of systolic blood pressure to 90 mm Hg for 30 minutes from a baseline of 120 mm Hg. This first re­ported case of pituitary apoplexy during liposuction surgery probably resulted from intraoperative hypotension attrib­uted to a combination of general anesthesia, the use of sub­cutaneous lidocaine, sequestration of plasma in injured tis­sues, and blood loss. ( JNeuro- Ophthalmol 2004; 24: 31- 33) Liposuction surgery, a procedure consisting of removal of undesirable body fat by suction cannulas, is the most frequently performed cosmetic procedure in the United States ( 1). Introduced in 1977, the wet technique of lipo­suction is performed under general anesthesia and involves infiltrating subcutaneous fat with a dilute solution of epi­nephrine in a volume equal to 10% of the estimated volume of fat removed ( 2). This technique allows safe removal of up to 1500 cc of adipose tissue ( 3). The newer technique, called " tumescent liposuction," is performed under local anesthesia and involves the ballooning of subcutaneous fat with several liters of 0.04- 0.1% lidocaine, 1: 10,000,000 epinephrine, and sodium bicarbonate in normal saline, followed by fat aspiration through microcannulas. The tumescent procedure allows for removal of a greater vol­ume of adipose tissue and minimizes blood loss ( 4, 5). Un­like the traditional technique, which is performed under From the UMDNJ- Robert Wood Johnson Medical School ( AC), and the Departments of Ophthalmology ( KK, LF), Radiology ( LW), and Neu-rosciences ( LF), UMDNJ- NJMS, Newark, New Jersey. Address correspondence to Larry Frohman, MD, Department of Oph­thalmology, UMDNJ- New Jersey Medical School, Newark, NJ 07103- 2441. E- mail: frohman@ umdnj. edu Supported in part by unrestricted grants from Research to Prevent Blindness, Inc., The Eye Institute of New Jersey, and the Goldring Family Foundation. general anesthesia without ballooning the subcutaneous fat with lidocaine, the tumescent technique employs injection of subcutaneous fat with lidocaine as the primary mode of anesthesia. We describe a case of pituitary apoplexy occurring during large volume liposuction performed under general anesthesia but using the tumescent technique of injecting a large dose of subcutaneous lidocaine into the subcutaneous fat. We attribute the pituitary apoplexy to hypotension caused the effects of general anesthesia together with those of the tumescent technique. Case Report A 50- year- old woman with no significant past medi­cal history underwent liposuction employing features of the traditional and tumescent techniques ( general anesthesia with subcutaneous lidocaine injection) on her abdomen, hips, and thighs. Her height and weight were 167 cm and 63 kg, respectively. Subcutaneous fat was injected with 2.5 L of 0.05% lidocaine and 1: 10,000,000 epinephrine in lactated Ringer's solution. Then 3000 mL of aspirate were removed and replaced with 3 L of lactated Ringer's solution during the 2.5 hour procedure. Review of the anesthesia record revealed that her systolic blood pressure dropped during the procedure to 90 mm Hg for 30 minutes from a baseline of 120 mm Hg. No blood transfusions were given. Her preoperative hemoglobin and hematocrit were 12.7 and 38, respectively. Estimated blood loss was 250 cc. Postop­erative hemoglobin and hematocrit were not evaluated. Upon awakening, she complained of intense head­ache and was unable to open her OD. Headache persisted, and she had nausea and vomiting the same day. A neuro­surgeon documented right- sided ptosis and " palsy of the right third, fourth, and sixth cranial nerves." MRI dem­onstrated a 2.7 x 2.7 x 3.2 cm intrasellar and suprasellar mass ( Fig. 1) extending into the right cavernous sinus. A hyperintense rim indicated the presence of blood products. On T2- weighted images there was a hypointense focus, suggesting recent bleeding. The diagnosis was pitui­tary apoplexy. The next morning, the patient underwent a transsphe­noidal resection of the pituitary mass, which showed J Neuro- Ophthalmol, Vol. 24, No. 1, 2004 31 JNeuro- Ophthalmol, Vol. 24, No. 1, 2004 Cohen et al. FIGURE 1. Postoperative brain MRI. A. Sagittal T- 1 image shows an intrasellar and suprasellar mass with a rim of hyper-intensity typical of methemoglobin in a subacute hemorrhage. B. Coronal T- 1 image shows the mass extending into the right cavernous sinus. C. Coronal T- 2 image shows the lesion to be homogeneously hyperintense with the exception of a medial hypointensity representing hemorrhage into the adenoma. typical features of a pituitary adenoma with gross infarction and several areas of hemorrhage. Her postoperative course was uneventful. Initial neuro- ophthalmic consultation was performed 6 weeks after the resection of the pituitary tumor. She had normal visual acuity, color plate vision, and automated 30° threshold visual fields. The pupils measured 6.0 mm in the dark, the right pupil reacting minimally to direct light, the left reacting normally; there was no relative afferent pupillary defect. The lid fissure heights measured 6 mm OD and 11 mm OS. There were moderate ductional deficits in all directions OD. Aberrant regeneration was not present. In primary distance gaze, she demonstrated an exotropia of 12 prism- diopters and a left hypertropia of 16 prism-diopters. Corneal sensation was normal OU. The rest of the examination, including ophthalmoscopy, was normal. One year after the apoplexy, the only residual abnor­malities were a slight anisocoria, a minimally reactive right pupil, a mild adduction and a moderate supraduction deficit OD, an exotropia of 12 prism- diopters, and a left hypertro­pia of 14 prism diopters in primary gaze position. DISCUSSION A national survey of more than 15,000 cases of tu­mescent liposuction reported in 1995 no major complica­tions and concluded that the procedure was exceptionally safe when performed under local anesthesia ( 6). However, the increasing popularity of the tumescent technique has led to a trend toward larger volume aspiration, together with a greater potential for new complications ( 7). The amount of tissue removal is of great clinical significance because re­sections of 3000 mT of aspirate or greater cause potentially significant blood loss and a redistribution of fluid from the intravascular to the interstitial space ( 8,9). Deaths follow­ing the procedure have been documented, but because it is not mandatory to report complications associated with tu­mescent liposuction, the exact incidence of adverse effects, including death, is not known ( 10). Some authors argue that tumescent liposuction is ex­tremely safe ( 6), while others claim that the larger volume resections have increased the potential of hypovolemia and fluid overload ( 11- 13). A recent study ( 10) identified five deaths from tumescent liposuction. Three of these deaths were attributed to precipitous intraoperative hypotension and bradycardia without a clearly identified cause; the fourth death was attributed to deep venous thrombosis of calf veins with pulmonary thromboembolism; the fifth death was attributed to fluid overload. Pituitary apoplexy is a potentially catastrophic event resulting from a sudden increase in the size of a pituitary gland secondary to hemorrhagic infarction. Pituitary apo­plexy most commonly occurs in patients with pituitary ad­enoma. Patients usually present with severe headache, nau­sea, vomiting, meningismus, and altered mental state. The syndrome may cause sudden death. Ophthalmologic mani­festations include chiasmal visual loss and ophthalmople­gia. The condition is thought to occur when a tumor spon­taneously hemorrhages or when it becomes infarcted and swells with necrosis, hemorrhage, and edema. Pituitary apoplexy may be a spontaneous manifestation of a pituitary tumor or precipitated by pregnancy, the postpartum state, systemic hypotension, or local radiation therapy ( 14). Man­agement of pituitary apoplexy often requires emergency re­moval of the mass. To our knowledge, this is the first reported case of pituitary apoplexy occurring during liposuction. This case is unusual in that a large dose of local anesthetic was in­jected into the subcutaneous fat while the patient was under general anesthesia. Our patient's hypotension and subse­quent pituitary apoplexy was likely caused by a combina­tion of factors. 32 © 2004 Lippincott Williams & Wilkins Pituitary Apoplexy During Large Volume Liposuction Surgery JNeuro- Ophthalmol, Vol. 24, No. 1, 2004 First, there is a greater risk of hypotension with gen­eral anesthesia than with local anesthesia. General anesthe­sia also may have resulted in a decrease in brain perfusion. Volatile general anesthetic agents produce a dose- related interference with cerebrovascular auto- regulation, causing perfusion to become pressure- dependent ( 15). Second, lidocaine injected into the subcutaneous fat may have caused hypotension by suppressing myocardial automaticity and producing peripheral vasodilation. Third, surgical tissue damage causes a diffusion of intravascular fluid into the interstitial space, leading to edema and a decrease in blood pressure. Recent literature ( 16) has documented the importance of meticulous fluid balance during large volume tumescent liposuction. A rec­ommended formula for fluid replacement during this pro­cedure has been established as a guideline ( 16). The for­mula consists of reconstituting the total volume of aspirate with an equal volume of replacement fluid. If more than 4 L of aspirate are removed, an additional 0.25 mL of intrave­nous crystalloid should be replenished per cubic centimeter of aspirate removed beyond 4 L. It is worth noting that fluid replacement in our case met the recommended guidelines. Fourth, blood loss also may have been a contributing factor. Although a blood loss of only 250 cc was docu­mented in the operative note, blood loss typically comprises 25 to 40% of the aspirate, with adipose tissue making up most of the remainder ( 8,9). Our patient had a large resec­tion, in that 3 L of aspirate were removed. Internal ( non-aspirated) blood losses, difficult to estimate ( 8,9), also may have occurred. In summary, we believe that the combination of gen­eral anesthesia ( hypotension and interference with cerebro­vascular autoregulation), subcutaneously injected lidocaine ( vasodilation and suppression of myocardial automaticity), surgical tissue damage ( redistribution of fluid volume be­tween intravascular and extravascular compartments), and procedure- associated blood loss likely led to a dramatic re­duction in perfusion of the pituitary gland. This mechanism is similar to that of Sheehan syndrome, where postpartum pituitary apoplexy occurs due to the hypotension associated with uterine hemorrhage and hypovolemia. REFERENCES 1. Rohrich, RJ, BeranSJ, FodorPB. The role of subcutaneous infiltra­tion in suction- assisted lipoplasty: A review. Plast Reconstr Surg 1997; 99: 514- 19. 2. Mladick RA, Morris RL. Sixteen months experience with the Illouz technique of lipolysis. Ann Plast Surg 1986; 16: 220- 32. 3. Chrisman BB, Coleman WP. Determining safe limits for untrans-fused outpatient liposuction: Personal experience and review of the literature. J Dermatol Surg Oncol 1988; 14: 1095- 102. 4. Klein JA. Tumescent technique for local anesthesia improves safety in large- volume liposuction. J Plast Reconstr Surg 1993; 92: 1085- 98. 5. Fodor PB. Defining wetting solutions in lipoplasty. Plast Reconstr Surg 1999; 103: 1519- 20. 6. Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients. 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