Delayed Cerebral Ischemia Associated with Surgery for Pituitary Macroadenomas That Express Elevated Levels of PACAP

Delayed cerebral ischemia (DCI) and cerebral vasospasm (VS) are rare but serious post-operative complications after surgery for pituitary macroadenomas; the mechanism of which are poorly understood. Pituitary adenylate cyclase-activating polypeptide (PACAP) is a vasoactive neuropeptide expressed in pituitary adenomas and may play a role in DCI/VS. The aim of this case-control study was to investigate the association between tumor expression of PACAP and DCI/VS following pituitary surgery. Tumor tissue from five patients with DCI/VS following pituitary surgery and nine matched controls were evaluated for PACAP expression by immunohistochemistry. Nuclear PACAP expression was significantly elevated in patients with DCI/VS following pituitary surgery compared to controls (0.396 +/- 0.0.16 a.u. vs 0.093 +/- 0.04 a.u, p < 0.0001). There was a positive linear relationship between nuclear PACAP expression and pre-operative tumor volume (r(2) = 0.41, p < 0.02) with a significant difference in slopes between the DCI/VS group compared to controls (y = x(5.0 x 10(-3)), r(2) = 0.76 vs y = x(7.4 x 10(-4)), r(2) = 0.07, p < 0.05). Elevated levels of tumor PACAP expression is associated with DCI/VS following pituitary surgery and may have a role in tumor growth. PACAP signaling may play a role the development of DCI, but further studies are needed.