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All in the timing

01 January 2013

Mr C, a 40-year-old carpenter, attended his local Emergency Department (ED) with a severe headache, vomiting, blurred vision and photophobia. These symptoms responded to analgesics and antiemetics. History and examination suggested possible intracranial pathology. The CT scan performed showed no evidence of a subarachnoid haemorrhage but did show a large tumour in the pituitary fossa.

Recently appointed consultant neurosurgeon Mr Y was soon involved in Mr C’s care. He requested immediate ophthalmology assessment and a visual field defect was excluded. Mr Y arranged a pituitary function test but proceeded before the result was available. Mr Y discussed the problem with Mr C and informed him that due to possible pituitary pressure on the optic nerves there was a high risk of blindness, and growth of the tumour might affect the function of the pituitary. Mr C agreed to immediate surgery.

Mr Y had very little experience of pituitary gland surgery. He chose a surgical approach that he felt familiar with, a left-sided fronto-temporal craniotomy, adopting a subfrontal and transsylvian approach to remove the tumour. The procedure was complicated as the tumour was very friable. Postoperatively Mr C had a dense hemiparesis. A repeat CT scan revealed extensive capsular infarct on the left side of the brain and a lacuna infarct on the right. It took several months for Mr C to recover any independence and he was left with right-sided permanent neurological damage with hemiparesis.

Subsequently he was also found to have raised prolactin levels and ACTH and gonadotropin deficiencies requiring hydrocortisone and testosterone. He made a claim against Mr Y. Expert opinion was critical of Mr Y’s management on various counts.

Preoperatively Mr C had normal vision so he was not at immediate risk of blindness as a consequence of pressure on the optic nerve. However as the tumour enlarged he may have been at risk of pituitary infarction (apoplexy), further affecting the hormonal function of the pituitary gland. Cases such as this are usually managed jointly with an endocrinologist who will assess the function of the anterior and posterior pituitary, by appropriate biochemical tests, such as stimulatory hormonal testing, and for posterior pituitary, a prolactin level.

Medical management could delay surgical intervention if the optic nerves were not at risk and the tumour size did not suggest a risk of infarction. The experts were also critical of the surgical approach, which was not in line with usual practice. They agreed that there was no clinical indication for the urgency with which this procedure was undertaken; had an MDT assessment been undertaken he wouldn’t have had surgery. The case had to be settled for a high sum.

Learning points

  • Patience and an awareness of one’s own expertise and knowledge are vital to practise safe surgery. It is rarely appropriate to rush into a procedure, particularly if this means there is a risk of taking an incorrect or risky approach.
  • A surgeon may need to take rapid and difficult decisions intraoperatively; however, preoperatively it is important to take appropriate time to review all investigation and treatment options to ensure the best outcome for the patient.
  • In medical practice recognising one’s limits (cognisance) and accepting that something may go beyond one’s expertise and training is essential for good medical practice. This might be particularly hard for newly-appointed consultants eager to establish their clinical practice and expertise to their senior colleagues.
  • It is important to gather all the facts available to define the clinical situation of the patient before deciding on any management plan. It is here that point or team working may be appropriate and helpful. In retrospect, in this patient, there were a number of unanswered questions such as the precise nature of the lesion; whether more tests should have been carried out to define the situation; whether the surgery was needed at that time; and whether the patient was at risk of pituitary apoplexy.
  • Working as a team provides an extra safety net to medical practice. In areas such as pituitary surgery, it is common practice nowadays to work in conjunction with the endocrinology team, who can give advice on the medical investigations to define the patient’s problem and assist in postoperative hormone replacement as appropriate.