Intraventricular haemorrhage by nasogastric tube insertion into the brain after transsphenoidal surgery. A case report and review of the literature

Background: Insertion of a nasogastric tube is a very common procedure in many clinical situations. Several complications associated with their use are well documented, but one of the most significant is inadvertent insertion into the brain. This fatal event has been widely described in patients with basal skull fractures after severe head injury. In contrast, it is an extremely rare complication in non-trauma patients and following transsphenoidal surgery. We report our unusual case in a patient who had undergone a microscopic transoral transsphenoidal surgery for a pituitary tumour and briefly review the literature. Case presentation: A giant pituitary adenoma was diagnosed in a 47-year-old woman after she experienced several episodes of seizures and acute hydrocephalus. Initially, a ventriculoperitoneal shunt was placed and microscopic transoral transsphenoidal surgery was carried out sometime later. Twelve days after the surgical procedure, a nasogastric tube was inserted to ensure effective enteral feeding. X-ray imaging was performed but, unfortunately, the shunt tubing was mistaken for the nasogastric tube. After the fatal insertion, the patient had uncontrollable seizures and a low level of consciousness. Brain computed tomography revealed an intraventricular haemorrhage and the tube coiled into the ventricular system and brain parenchyma, passing through the sella and with its distal end pointing towards the occipital region. The nasogastric tube (70 cm in length) was carefully removed through the nasal route under aseptic conditions and general anaesthesia in the operating room, and subsequently, external ventricular drainage was inserted. Despite all efforts, the patient died 8 days later. Conclusions: Special care should be taken when inserting a nasogastric tube in patients with head trauma, craniofacial injury, or a history of sinusitis or meningitis infection, as well as after maxillofacial or trans sphenoidal surgery. Further, there is a need to assess whether nasogastric tube placement can be avoided in certain patients. We should consider the use of one of the alternative methods of gastric tube placement that have been described, including orogastric intubation, fluoroscopically-guided nasogastric intubation and tube insertion under a direct visual control with a flexible nasopharyngolaryngoscopy or a simple laryngoscope. On the other hand, if this devastating event occurs, it is essential to remove the nasogastric tube under aseptic conditions together with depth of anaesthesia monitoring. It should preferably be removed endoscopically through the nasal route followed by dural repair if a cerebrospinal fluid leak is detected.