Postoperative symptomatic vasospasm in pituitary surgery: case series and systematic review - a matter of blood?

Vasospasm is an unusual complication after pituitary surgery with potentially severe sequelae. There is limited information available in the literature concerning risk, patterns, outcomes and therapy. This systematic review investigates reported cases between 1956 and 2025 to improve assessment and management of this phenomenon. Pubmed database was systematically screened between 1st January 1969 and 10th October 2025 for medical subject headings (MeSH-terms) ‘Vasospasm’ OR ‘Delayed cerebral ischemia’ OR ‘Delayed neurological deficit’ AND ‘pituitary surgery’. The first description by Krayenbühl in 1956 was included as only report that could be identified before 1969. Overall, 262 articles were identified and abstracts screened. Afterwards, 59 articles were reviewed identifying 114 patients and excluding 205 patients. Additionally, three original cases are reported. Vasospasm after pituitary surgery is most often reported after resection of large non-functioning pituitary adenomas (50/117) or craniopharyngiomas (25/117). Vasospasm manifests predominantly between the fifth and twelfth postoperative day (73%) with altered sensorium, palsy or aphasia and affects ICA, MCA, ACA or their combinations in more than 90% of cases. Tumor bed hemorrhage was present in 75% of cases with reported early postoperative MR or CT imaging. Therapy is not standardized, more than half of reported patients suffer permanent neurological morbidity (36.7%) or mortality (19.4%). Vasospasm after pituitary surgery is rare but devastating in an otherwise benign disease. This systematic review suggests an association with tumor bed hemorrhage and marked similarities with subarachnoid hemorrhage induced vasospasm. Patients at risk should be defined preoperatively and closely monitored postoperatively.