Safety of emergency endoscopic endonasal surgery in COVID-positive patients with hemorrhagic complications of pituitary region tumors: A case report and review of the literature

Background: Pituitary apoplexy (PA) is a rare, life-threatening clinical syndrome that occurs in response to acute ischemic infarction or hemorrhage of a pituitary adenoma. We report two cases of sudden neurologic and visual decline in patients with pituitary region masses in coronavirus disease (COVID)-positive patients with a focus on potential pathophysiological mechanisms and a safe approach to treatment.

Case description: Case one is a 58-year-old male presenting with sudden-onset headache and visual disturbance. He was febrile and tested positive for COVID-19. Magnetic resonance imaging (MRI) revealed a large sellarsuprasellar mass with intratumoral hemorrhagic components. He underwent endoscopic endonasal resection with subsequent improvement in vision and oculomotor function. Pathology was consistent with hemorrhagic pituitary adenoma. Case two is a 15-year-old male presenting with sudden-onset severe headache and acute visual loss. He also tested positive for COVID-19. MRI revealed a sellar-suprasellar mass with a regional mass effect. He underwent endoscopic endonasal resection with improvement in vision over time. Pathology was consistent with craniopharyngioma. There was no evidence of intraoperative COVID-19 transmission among members of the surgical team, who were monitored for 2 weeks after surgery.

Conclusion: PA in the setting of severe acute respiratory syndrome coronavirus 2 infection should be considered in the differential diagnosis of a COVID-positive patient presenting with acute severe headache, visual loss, and/or ophthalmoplegia; we discuss proposed mechanisms related to inflammation, coagulability, and hypoxia. The absence of intraoperative COVID-19 transmission during transsphenoidal resection performed in an emergency setting suggests that the risk of exposure may be attenuated with safety precautions.