A Case of Suprasellar Pi̇locyti̇c Astrocytoma Wi̇th Plasmi̇nogen Acti̇vator Inhi̇bi̇tor-1 4g/4g Genotype: Rare Severe Vasospasm and Cli̇ni̇cal Effects After Endoscopi̇c Transphenoi̇dal Surgery

Abstract Background Cerebral vasospasm following endoscopic transsphenoidal surgery is rare. In this study, we present a case of sellar-suprasellar pilocytic astrocytoma with the rare and serious complication of cerebral vasospasm after endoscopic transsphenoidal surgery, who had plasminogen activator inhibitor type-1 4G/4G genotype. Case description A 7-year-old female patient presented with complaints of headache and nausea. Upon detection of a lesion in the sellar-suprasellar region, initial intervention involved tumor excision and placement of an extraventricular drainage catheter through a transcranial anterior interhemispheric approach, followed by endoscopic transsphenoidal surgery for tumor excision seven days later. On the fifth day after endoscopic transsphenoidal surgery, the patient, who exhibited a tendency to somnolence, aphasia, and right hemiplegia, demonstrated significant stenosis at the proximal portions of the internal carotid artery bifurcation, M1, and A1 segments. Successful treatment was achieved through endovascular balloon angioplasty. Hydrocephalus did not develop during follow-up, and no shunt was required. Pathology revealed pilocytic astrocytoma (WHO grade I, 2021). Adjuvant treatment was not administered. At six months postoperatively, aphasia and right hemiplegia showed marked improvement. A thrombophilia panel performed in the postoperative period resulted in plasminogen activator inhibitor type-1 4G/4G homozygosity. The patient, who completed one year of follow-up, continues to be monitored with a modified Rankin Scale score of 1. Conclusion In cases of unexpected neurological deterioration following endoscopic transsphenoidal surgery, symptomatic cerebral vasospasm should be considered in the differential diagnosis, and early and aggressive treatment should be administered. A multidisciplinary approach is crucial for the optimal management of potential complications. Further case series and studies are needed to establish a strong correlation between PAI-1 4G/4G homozygosity and cerebral vasospasm.