38

Surg Neurol
1985;23:38-40

Vasospasm After Acoustic Neuroma Removal
G i l b e r t o M a c h a d o d e A l m e i d a , M . D . , E d u a r d o B i a n c o , M . D . , a n d A l f r e d o S. S o u z a , M . D .
Department of Neurosurgery, Hospital Nove de Julho, Sgo Paulo, Brazil.

de Almeida GM, Bianco E, Souza AS. Vasospasm after acoustic
neuroma removal. Surg Neurol 1985;23:38-40.

A case of a acoustic neuroma with a two-stage removal
due to severe bleeding is presented. The patient remained
drowsy after the second operation and by the 8th day
deteriorated quickly with progressive right hemiplegia
and aphasia. The cerebrospinal fluid was bloody, vasospasm was shown in the angiograms, and an ischemic area
was disclosed in the computed tomography scan. The outcome and the neuroradiologic examinations suggested that
blood in the basal cisterns caused the vasospasm and the
brain ischemia. A review of the literature disclosed only
one similar case.
KEYWORDS: Subarachnoid hemorrhage; Cerebral vasospasm;
Acoustic neuroma

creased hearing. X-rays of the skull, vertebral angiogram, and computed tomography scan showed a right
acoustic neuroma, measuring about 50 mm in its largest
diameter.

First Operation
On July 14, 1982 with the patient placed in left lateral
decubitus, a right suboccipital craniectomy was carried
out. The acoustic porus was enlarged with a diamond
drill, and the facial nerve was identified at the porus.
Only a partial removal was performed because the tumor
was highly vascular and bled excessively. The postoperative course was uneventful, but a right facial paresis
was noticed.

Second Operation
In the last two decades many clinical and experimental
studies have discussed the etiology, pathology, clinical
significance, prevention, and treatment o f vasospasm related to aneurysmal rupture and aneurysmal surgery
[3,10,12,18,22,24,28,31]. Vasospasm due to other causes
of subarachnoid hemorrhage such as bleeding from an
angioma, head injury, or operations on tumors is less
frequent. In a recent case report o f vasospasm after a
removal of a pituitary tumor, Hyde-Rowan et al [11]
mentioned only eight similar cases. As far as we are
aware, vasospasm after removal of an acoustic neuroma
has been reported only once [13].
Case Report
A 26-year-old man was admitted to the Hospital Nove
de Julho (Sgto Paulo) in July 1982, for treatment of a
large cerebellopontine angle tumor. For 8 months before admission the patient had been suffering from pain
in the distribution of the second branch of the right
trigeminal nerve. H e had noticed a hearing disturbance
on the right side.
Neurologic examination disclosed decreased right
corneal reflex, horizontal nistagmus, and right-sided deAddress reprint requests to." Gilberto Machado de Almeida, Caixa
Postal 11488, 05499 Sao Paulo, Brazil.

© 1985 by Elsevier Science PublishingCo., Inc.

On July 29, 1982 the craniectomy was reopened with
the patient in the same "park bench" position and the
remaining tumor was removed. At this time the bleeding
was again remarkable. The facial nerve was sacrificed
because the tumor was firmly attached to the nerve.

Postoperative Course
After the operation the patient was drowsy, with stiffness of his neck. On August 6, 1982 the patient deteriorated progressively and after 8 hours was aphasic and
had hemiplegia on the right side. On the same day a
lumbar puncture disclosed hemorrhagic cerelbrospinal
fluid. The spinal fluid analysis showed 160,000 red blood
cells per milliliter, 960 white blood cells per milliliter
(16% polymorphonuclear leukocytes), 1,040 mg% of
protein, and 31 m g % of glucose. The cerelbrospinal
fluid culture was negative. The computed tomography
scan on the same day and again 2 days later disclosed
only postoperative changes in the posterior fossa. On
August 12, 6 days after the deterioration, an angiogram
of the carotid artery showed vasospasm of the supraclinoid portion of the internal carotid artery and of the
proximal segments of the anterior and middle cerebral
arteries (Figure 1). On August 19, a small left parietal
ischemic area was seen in the computed tomagraphy scan
(Figure 2). The neurologic deficits improved progressively. One year later the patient remained with a right
0090-3019/85/$3.30

Vasospasm and Acoustic Neuroma Removal

Surg Neurol
1985;23:38-40

39

A

B

Figure 1. Angiogram of the left internal carotid artery,anterioposterior
view (A), lateral view (B). Vasospasm of the supraclinoid portion of the
internal carotid artery and of the proximal segments of the anterior and
middle cerebral arteries is clearly shown.

Intracranial arterial spasm unrelated to intracranial
bleeding has been reported in episodes of different types
of vascular headaches [5,8,14]. This vasospasm can not
be correlated with the one due to aneurysmal rupture.
Fein [6] reporting on unruptured aneurysms concluded
that subarachnoid hemorrhage is a necessary c o m p o n e n t
for the development of clinically significant vasospasm.

facial palsy and with a light monoparesis on the right
side in the lower limb. In April 1983 a facial-facial
anastomosis was tried.

Discussion
Vasospasm unrelated to aneurysm rupture or aneurysmal surgery is rare [1,I7,27].
Posttraumatic intracranial artery spasm has been occasionally reported [2,26]. According to Arseni et al
[2], the contusion of the arterial inner wall favors the
development of spasm and thrombi. In most of the reported cases reopening of the vessels leads to the conclusion that the obstruction was caused by spasm. The
persistence o f incomplete filling of the arteries suggests
an inner wall traumatic lesion [2]. We believe that the
role played by the subarachnoid hemorrhage can not be
ruled out when direct trauma to the arteries can not be
proved.
Vasospasm after removal o f a tumor is rare and usually is related to operation on pituitary tumors [4,11,15].
T r a u m a to the arterial walls can not be ruled out as its
cause in those cases. Wilson and Field [29] and Wilkins
[23,25] demonstrated a possible relation between hypothalamic dysfunction and vasospasm. Hypothalamic
lesions could then also be the cause of vasospasm after
removal of pituitary tumors.
Smith et al [21] reported a case o f cerebral vasospasm
after myelography, "It is uncertain whether the principal
cause o f this response was Pantopaque, subarachnoid
blood, or the combination thereof."

Figure 2. Computed tomography scan showing an ischemic area with some
contrast-medium enhancement.

40

Surg Neurol
1985;23:38-40

Recently, vasospasm was detected in a patient with an
unruptured and unoperated aneurysm [7].
Reports o f major hemorrhage from acoustic neuromas are u n c o m m o n [9,16,19,30] and vasospasm was not
reported in those cases.
Krayenb~ihl [13] discussing the dynamics o f vasospasm reports briefly on a patient with internal carotid
spasm after removal of an acoustic neuroma. The amount
o f bleeding and the patient's position were not mentioned. The deterioration occurred on the 13th day and
the angiogram disclosed the vasospasm. About 20 days
later, another angiogram was normal.
It is n o w widely accepted that subarachnoid blood
after rupture o f aneurysms plays a major role in the
development o f vasospasm [20]. H o w e v e r , the substances directly involved in the production o f vasospasm
[3,18,20,24,31] and the importance of other factors such
as trauma to the arterial wall [2,11,26] or hypothalamic
injury [23,25,29] are still controversial.
In our case the vasospasm was probably caused by a
large amount o f blood in the basal cisterns. Angiographically this tumor did not appear hypervascular but the
intraoperative bleeding was remarkable. Once the patient was in a left lateral position, we suspect that a large
amount o f blood accumulated in the basal cisterns, mostly
on the left side. In our patient there was no direct trauma
to the arterial walls or direct hypothalamic lesion. So,
the accumulation o f blood around the involved arteries
is probably the cause o f the vasospasm. The characteristics o f the deterioration on the eighth postoperative
day correlate with the typical clinical picture o f cerebral
vasospasm [31]. The angiogram and the computed tomography scan confirmed the presence o f spasm and
infarction.

References
1. Adams CBT. Vasospasm: occurence in conditions other than subarachnoid hemorrhage from a bleeding aneurysm. In: Wilkins
RH, ed. Cerebral arterial spasm. Baltimore: Williams & Wilkins,
1980:471.
2. Arseni C, Maretsis M, Horvath L. Postraumatic intracranial arterial spasm: report of three cases. Acta Neurochir (Wien)
1971;24:25-35.
3. Boullin DJ, Tagari P, Du Boulay G, Aitken V, Hughes JT. The
role of hemoglobin in the etiology of cerebral vasospasm: an in
vivo study of baboons. J Neurosurg 1983;59:231-6.
4. Camp PE, Paxton HD, Buchan GC, Gahbauer H. Vasospasm
after transsphenoidal hypophysectomy. Neurosurgery 1980;
7:382-5.
5. Dukes HT, Vieth RG. Cerebral arteriography during migraine
prodrome and headache. Neurology (Minneap) 1964;14:636-9.
6. FeinJM. Unruptured aneurysms and cerebralvasospasm. In:Wilkins RH, ed. Cerebral arterial spasm. Baltimore: Williams & Wilkins, 1980:499-504.
7. Friedman P, Gass HH, Magidson M. Vasospasm with an unruptured and unoperated aneurysm. Surg Neurol 1983;19:21-5.

de Ameida et al

8. Garnic JD, Schellinger D. Arterial spasm as a finding intimately
associated with the oncet as vascular headache. Neuroradiology
1983;24:273-6.
9. Gleeson RK, ButzerJF, Grin OO. Acoustic neurinoma presenting
as subarachnoid hemorrhage. Case report. J Neurosurg
1978;49:602-4.
10. Graham DI, Macpherson P, Pitts LH. Correlation between angiographic vasospasm, hematoma and ischemic brain damage following SAH. J Neurosurg 1983;59:223-30.
11. Hyde-Rowan MD, Roessmann V, Brodkey JS. Vasospasm following transsphenoidal tumor removal associate with the arterial
changes of oral contraception. Surg Neurol 1983;20:120-4.
12. Kapp JP, Neill CL, Hodges LR, Smith RR. The three phases of
vasospasm. Surg Neurol 1982;18:40-5.
13. Krayenbi~hl H. Beitrag zur Frage des cerebralen angiopastischen
Insults. Schweiz Med Wochenschr 1960;90:961-5.
14. Masuzawa T, Shinoda S, Furuse M, Nakahara N, Abe F, Sato F.
Cerebral angiographic changes on serial examination of a patient
with migraine. Neuroradiology 1983;24:277-81.
15. Mawk JR, Ausman JI, Erickson OL, Maxwell RE. Vasospasm
following transcranial removal of large pituitary adenomas. J Neurosurg 1979;50:229-32.
16. McCoyd K, Barron KD, Cassidy RJ. Acoustic neurinoma presenting as subarachnoid hemorrhage: case report. J Neurosurg
1974;41:391-3.
17. Peerless SJ. Postoperative cerebral vasospasm without subarachnoid hemorrhage. In: Wilkins RH, ed. Cerebral arterial spasm.
Baltimore: Williams & Wikins, 1980:496-8.
18. Schumacker MA, Alksne JF. Mechanisms of whole blood-induced
cerebral arterial contraction. Neurosurgery 1981;9:275-82.
19. Shephard RH, Cheeks RE. Subarachnoid hemorrhage and acoustic neurome. J Neurol Neurosurg Psychiatry 1981;44:1057.
20. Shigeno T. Norepinephrine in cerebrospinal fluid of patients with
cerebral vasospasm. J Neurosurg 1982;56:344-9.
21. Smith RA, Collier HF, Underwood FO. Cerebral vasospasm following myelography. Surg Neurol 1973;1:87-90.
22. Suzuki J, Yoshimoto T, Onuma T. Early operations for ruptured
intracranial aneurysms: study of 31 cases operated on within the
first four days after ruptured aneurysm. Neurol Med Chir (Tokyo)
1978;18 (Pt I):83-9.
23. Wilkins RH. Hypothalamic dysfunction and intracranial arterial
spasm. Surg Neurol 1975;4:472-80.
24. Wilkins RH. Cerebral arterial spasm. Baltimore: Williams & Wilkins, 1980:699.
25. Wilkins RH. The possible role of the hypothalamus in the development of intracranial arterial spasm. In: Wilkins RH, ed.
Cerebral arterial spasm. Baltimore: Williams & Wilkins,
1980:266-9.
26. Wilkins RH. Trauma-induced cerebral vasospasm. In: Wilkins
RH, ed. Cerebral arterial spasm. Baltimore: Williams & Wilkins,
1980:472-5.
27. Wilkins RH. Intracranial arterial spasm after procedures other
than operations for intracranial aneurysm. In: Wilkins RH, ed.
Cerebral arterial spasm. Baltimore: Williams & Wilkins,
1980:505-9.
28. Wilkins RH. Attempted prevention or treatment of intracranial
arterial spasm: a survey. Neurosurgery 1980;6:198-210.
29. WilsonJL, FeildJR. The production ofintracranialvascular spasm
by hypothalamic extract. J Neurosurg 1974;40:473-9.
30. Yonemitsu T, Niizuma H, Kodama N, Fujiwara S, SuzukiJ. Acoustic
neurinoma presenting as subarachnoid hemorrhage. Surg Neurol
1983;20:125-30.
31. Zervas NT. Vasospasm: an update. Clin Neurosurg 1979;
26:643-56.