Management of Pheochromocytoma in The Setting of Acute Stroke

ABSTRACT Objective: Stroke is a rare presenting symptom of pheochromocytoma; therefore, a balance between adequate pre-operative medical blockade and expedition of surgery to minimize the risk of further peri-operative stroke is needed. However, currently there are no established guidelines regarding timing of surgery or length of pre-operative blockade in these patients. We report a case of pheochromocytoma in a 53-year-old woman presenting with a hemorrhagic transformation of an ischemic stroke. We describe the clinical course, diagnosis, and management of our case and then discuss similar cases in the literature as well as optimal pre-operative management. Methods: We review all clinical data and describe the patient presentation and treatment. A comprehensive literature review of the topic is discussed. Results: Pheochromocytoma in our patient presented as a combination of stroke, severe hypertension, and tachycardia. A computed tomography scan, evaluation of catecholamine levels, and 123iodine-labeled metaiodobenzylguanidine scan confirmed pheochromocytoma. Hemodynamic stability was achieved after 9 weeks of treatment with selective alpha-blockade and other antihypertensive medications, after which laparoscopic transabdominal adrenalectomy was performed. Despite a normal blood pressure at pre-induction, the patient experienced 6 episodes of severe hypertension intra-operatively. There were no operative complications and hypertension resolved postoperatively. A review of the literature identified 5 similar cases; however, the optimal management of these patients remains unclear. Conclusion: Our case highlights the importance of including pheochromocytoma in the differential diagnosis of patients with stroke. Optimal results may be achieved by ensuring at least 6 weeks of recovery following stroke, and inducing orthostatic hypotension for at least 2 weeks prior to the surgery. Abbreviation: CT computed tomography