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MRI of the brain revealed a large pituitary tumor that extended superiorly in the suprasellar cistern to elevate the optic chiasm and extended inferiorly to fill the sphenoid sinus. (A, B) The mass was isointense to brain parenchyma on T1-weighted MRI, (C) relatively hypointense on T2-weighted MRI. (D-F) Showed significant contrast enhancement after injection of gadolinium. There was abnormal signal intensity consistent with acute hemorrhage in the tumor (black arrow).
Source publication
Epistaxis due to ruptured internal carotid artery (ICA) aneurysm embedded within a pituitary adenoma (PA) has seldom been reported in the literature. Here we want to elaborate the incidence, mechanisms, clinical manifestations, and treatment strategy for this condition. The first survived case of a patient with epistaxis and pituitary apoplexy due...
Contexts in source publication
Context 1
... bright mass within the sella was consistent with pituitary apoplexy (Figure 1). MRI of the brain revealed a large pituitary tumor that extended superiorly in the suprasellar cistern to elevate the optic chiasm and extended inferiorly to fill the sphenoid sinus ( Figure 2). The mass was isointense to the brain parenchyma on T1-weighted MRI, relatively hypointense on T2-weighted MRI, and showed significant contrast enhancement after injection of gadolinium. ...
Context 2
... was abnormal signal intensity consistent with acute hemorrhage in the tumor. Furthermore, an aneurysm-like flow-void was not observed adjacent to the right ICA in the sella turcica (Figure 2). ...
Context 3
... permanent occlusion was performed using two detachable 8×20 mm Gold Valve balloons (Nycomed, Ingenor, France) deployed in the petrous RICA and distal cervical RICA (Figure 4). In postoperative reevaluation, the preoperative MRI disclosed that the RICA protruded a small abnormal signal into the intratumoral hematoma, which might indicate a ruptured aneurysm (Figure 2). No new neurological deficit developed after this procedure. ...
Context 4
... results indicate that misdiagnosis of such coexistence can be possible. In our case, the axial and coronal MR images presented an abnormal signal and no flow void in the medial portion of the right ICA (Figure 2). We suspected that the presence of an unusual signal suggested a vascular component from the ICA. ...
Citations
... Precipitating factors have been identified in up to 30-40% of PA cases [39]. These include arterial hypertension and diabetes mellitus; major surgery (especially coronary artery bypass graft surgery); antiplatelet, anticoagulant, and fibrinolytic therapy; coagulation disorders; pregnancy; complicated delivery; severe hypotension and shock; head trauma; pituitary stimulation tests with gonadotropin-releasing hormone (GnRH), thyrotropin-releasing hormone (TRH), corticotropin-releasing hormone (CRH), or insulin hypoglycemia; radiotherapy; GH-and ACTH-secreting PitNETs and large NF-PitNETs, especially silent corticotropinomas; aneurysm rupture; and medications such as estrogens, somatostatin analogs, and dopamine agonists [35,[40][41][42][43][44][45][46][47][48][49][50]. In this context, it is important to inform all patients with pituitary tumors, especially those with potential precipitating factors, about the symptoms of PA for early detection and appropriate treatment. ...
Pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland. It is clinically characterized by the sudden onset of headache. Depending on the severity, it may also be accompanied by nausea, vomiting, visual disturbances, varying degrees of adenohypophyseal hormone deficiency, and decreased level of consciousness. Corticotropic axis involvement may result in severe hypotension and contribute to impaired level of consciousness. Precipitating factors are present in up to 30% of cases. PA may occur at any age and sometimes develops during pregnancy or the immediate postpartum period. PA occurs more frequently in men aged 50–60, being rare in children and adolescents. It can develop in healthy pituitary glands or those affected by inflammation, infection, or tumor. The main cause of PA is usually spontaneous hemorrhage or infarction of a pituitary adenoma (pituitary neuroendocrine tumor, PitNET). It is a medical emergency requiring immediate attention and, in many cases, urgent surgical intervention and long-term follow-up. Although the majority of patients (70%) require surgery, about one-third can be treated conservatively, mainly by monitoring fluid and electrolyte levels and using intravenous glucocorticoids. There are scoring systems for PA with implications for management and therapeutic outcomes that can help guide therapeutic decisions. Management of PA requires proper evaluation and long-term follow-up by a multidisciplinary team with expertise in pituitary pathology. The aim of the review is to summarize and update the most relevant aspects of the epidemiology, etiopathogenesis, pathophysiology, clinical presentation and clinical forms, diagnosis, therapeutic strategies, and prognosis of PA.
... Table 1 summarizes the details of this case and seven other similar cases. [7][8][9][11][12][13][14] The cases are listed in order according to the publication year. All the pituitary tumors in the present review were prolactinomas, which caused an intracranial hemorrhage in six of eight cases. ...
A 61-year-old man presented with massive epistaxis, amaurosis, nausea, and severe headache. A detailed examination revealed a subarachnoid hemorrhage and prolactinoma. Angiography showed a small internal carotid artery pseudoaneurysm and inadequate collateral circulation; thus, uncomplicated coil embolization was performed. Considering the side effects of medication, such as cerebrospinal fluid rhinorrhea, the patient was followed up for asymptomatic prolactinoma without medication after discharge. At 40 months later, aneurysm recurrence was confirmed. Flow diverter device placement was performed, and the outcomes were excellent. In the present report, we described a rare case of a ruptured internal carotid artery aneurysm in an untreated prolactinoma and discussed the literature.
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... Тактика лечения интраселлярных аневризм зависит от их размера и формы. Возможны как деконструктивные операции при адекватном коллатеральном кровотоке [25,26,40], так и сосудосохраняющие операции в виде койлинга или установки поток-перенаправляющего стента при условии подходящих анатомических особенностей [41]. В описанных нами случаях при проведении селективной ангиографии интраоперационно обращали на себя внимание практически полная дисплазия ВСА на уровне аневризм, крайне неблагоприятные анатомические характеристики аневризмы, включая угол отхождения ВСА дистальнее аневризм, что, в свою очередь, не позволило провести реконструктивную операцию с использованием поток-перенаправляющих стентов, и в результате были выполнены деконструктивные операции. ...
Background. The problem of concomitant pituitary adenomas and intracranial aneurysms is extensively covered in literature. According to various authors, the prevalence of such a combination of lesions is as high as 9 %, most commonly involving hormone‑producing pituitary adenomas and aneurysms of the anterior circulation, up to 69 % of which originate from the carotid artery.
Aim. To analyze and demonstrate the treatment of patients with developed internal carotid artery aneurysm (ICA) against the background of successful conservative therapy of prolactinoma. Materials and methods. In this article we review the literature and present two clinical cases of patients with development of internal carotid artery (ICA) aneurysms after successful conservative treatment of prolactinomas.
Results. In both of the described cases, ICA aneurysms with intrasellar extension developed after successful conservative treatment of large invasive prolactinomas. In both cases ICA occlusion were performed and in one of them extra‑intracranial bypass surgery was performed as well.
Conclusion. The presented clinical cases suggest potential direct destructive effect of tumor tissue on vessel walls. Currently, it seems reasonable to carry out computed tomography angiography in all patients with adenomas invading the cavernous sinus.
... 3 By mean of both autoptic and retrospective studies, with incidence rates ranging from 0.5 to 7.4%, 4-6 coincidental aneurysms are reported almost seven times more frequently in patients with PAs than in patients with other types of brain tumors. 3,7 Several mechanisms of aneurysm formation associated with PA have been proposed, including local circulatory stress, endocrine effect, mechanical effect, and direct invasion. It is possible that one or more mechanisms play a role in aneurysm formation at locations, but whether the PA contributes to aneurysm formation is still unclear. ...
... It is possible that one or more mechanisms play a role in aneurysm formation at locations, but whether the PA contributes to aneurysm formation is still unclear. 7 In the literature, over the decades, there have been sporadically numerous reported cases of this association, in some cases even very large series have been presented with more than 500 cases; however, the analyses of the characteristics of PAs, aneurysms, and treatment management are very rare and limited to a restricted minimum of case reports or clinical images. The great majority of these aneurysms are located outside the tumor itself. ...
... The presence of an internal carotid artery (ICA) aneurysm embedded within a PA located inside the sella turcica has rarely been reported. 7 So, reported cases of giant PA are even rarer where extrasellar growth may result in fully embedded intracranial aneurysm (IA) in the tumor. Giant prolactinomas are a rare subset of macroadenoma characterized by large size (more than 40 mm in diameter), high aggressiveness, and massive extrasellar involvement. ...
The coexistence of intracranial aneurysm (IA) is generally thought to be highest in patients with pituitary adenomas (PAs). Different mechanisms may play a role in aneurysm formation, but whether the PA contributes to aneurysm formation is still unclear. In the literature, there are numerous reported cases of this association; however, the analyses of the characteristics of PAs, aneurysms, and treatment management are rare and limited to a restricted number of case reports. We report a rare case of an embedded aneurysm in a macroprolactinoma treated with therapeutic management tailored to the clinical, neurological, and radiological characteristics of the patient. To select the best treatment, we reviewed the literature and reported the only cases in which the radiological characteristics of aneurysms, PAs, therapeutic management, and patient outcome are described. We aimed to understand what are the variables that determine the best therapeutic management with the best possible outcome. The presence of a large pseudoaneurysm of the internal carotid artery completely embedded in a giant macroprolactinoma is rare and needs a tailored treatment strategy. The importance of the preoperative knowledge of asymptomatic IA coexisting with PA can avoid accidental rupture of the aneurysm during surgical resection and may lead to planning the best treatment. A high degree of suspicion for an associated aneurysm is needed, and if magnetic resonance imaging shows some atypical features, digital subtraction angiography must be performed prior to contemplating any intervention to avoid iatrogenic aneurysmal rupture. Our multimodal approach with the first-line therapy of low-dose cabergoline to obtain prolactin normalization with minimum risks of aneurysms rupture and subsequent endovascular treatment with flow diverter has not been described elsewhere to our knowledge. In the cases, we suggest adopting a tailored low-dose cabergoline therapy scheme to avoid rupture during cytoreduction and initiate a close neuroradiological follow-up program.
... 17 MRI and MR angiography are considered the procedures of choice in the preoperative assessment of patients with pituitary tumors. The presence of flow voids on T1-weighted and T2-weighted MRI sequences is 100% specific for aneurysms with a sensitivity of 88% 18,19 it has been reported that only 80% of giant aneurysms show signs of blood flow in the aneurysm sac. 20,21 MRI may not be effective to detail small-sized intracranial aneurysms. ...
BACKGROUND
Unruptured incidental intracranial aneurysm can coexist with pituitary adenoma, however, the occurrence is extremely rare. Timely diagnosis of asymptomatic intracranial aneurysms with pituitary adenoma may lead to planning a tailored surgical strategy to deal with both pathologies simultaneously. A case of a patient who underwent transcranial resection of a pituitary adenoma with clipping of two mirror aneurysms is reported.
OBSERVATIONS
A 55-year-old female presented with deterioration of visual acuity that progressed over 1 year, as well as presence of right eyelid ptosis. Magnetic resonance imaging of the head showed the presence of an intrasellar pituitary macroadenoma. Bilateral paraclinoid aneurysms were documented to be in contact with the pituitary tumor. The patient underwent surgery with simultaneous aneurysm clipping and tumor resection through a standard pterional approach with intradural clinoidectomy. The aneurysms were successfully clipped after the tumoral debulking. After clipping, the pseudocapsule was fully resected.
LESSONS
Various treatment options are available. Although endovascular securing of the aneurysms prior to the tumor resection would be ideal, in cases in which this resource is not readily available at all times, the surgeon must be prepared to solve pathologies with an elevated level of complexity.
... 5 Rupture of aneurysms extending within pituitary adenomas, however, may present as pituitary apoplexy with visual, cranial nerve, and endocrine dysfunction. 12 Additionally, cavernous aneurysms located within pituitary adenomas carry risk for catastrophic rupture during surgical resection of these tumors. While the mortality rate for aneurysm rupture during pituitary surgery is not known, a 14% mortality rate after carotid artery injury during transsphenoidal surgery has been reported with a 24% rate of significant neurological disability. ...
Introduction Pituitary adenomas are a common intracranial pathology with an incidence of 15 to 20% in the population while cerebral aneurysms are less common with a prevalence of 1:50 patients. The incidence of aneurysms in patients with pituitary adenoma has been estimated at 2.3 to 5.4% of patients; however, this remains unclear. Equally, the management of concomitant lesions lacks significant understanding.
Methods A case report is presented of a concomitant cerebral aneurysm and pituitary adenoma managed by minimally invasive endovascular and endoscopic methods, respectively. A systematic review of the literature for terms “pituitary adenoma” and “aneurysm” yielded 494 studies that were narrowed to 19 relevant articles.
Results We report a case of a 67-year-old patient with an enlarging pituitary macroadenoma, cavernous carotid aneurysm, and unilateral carotid occlusion. After successful treatment of the aneurysm by a pipeline flow diverter, the pituitary adenoma was surgically resected by an endoscopic transsphenoidal approach.
Conclusion The use of a pipeline flow diverter and endonasal approach was feasible in the treatment of our patient. This is the first report to our knowledge of the use of pipeline flow diversion in the management of a cavernous carotid aneurysm prior to pituitary adenoma treatment.
... 5 Other experts believe that no standard treatment exists for pituitary adenoma with an intracranial aneurysm and that personalized treatment should be administered according to size, location, and interrelationship of the tumors and patient condition. 15 Nevertheless, for patients with pituitary apoplexy complicated by cerebral infarction due to occlusive ICA, there are still reports of new hemorrhagic transformation of the primary infarct after recanalization of the ICA. 16 Thus, some researchers suggest that for patients with cerebral infarction caused by pituitary apoplexy combined with occlusive ICA, endoscopic surgery can be performed after a patient is stabilized to prevent cerebral hemisphere if there are no vision and visual field disorders hemorrhagic infarction from maintaining a stable cerebral circulation. ...
BACKGROUND
Approximately 0.6% to 12% of cases of pituitary adenoma are complicated by apoplexy, and nearly 6% of pituitary adenomas are comorbid aneurysms. Occlusion of the internal carotid artery (ICA) with hidden intracranial aneurysm due to compression by an apoplectic pituitary adenoma is extremely rare; thus, the surgical strategy is also unknown.
OBSERVATIONS
The authors reported the case of a 48-year-old man with a large pituitary adenoma with coexisting ICA occlusion. After endoscopic transnasal surgery, repeated computed tomography angiography (CTA) demonstrated reperfusion of the left ICA but with a new-found aneurysm in the left posterior communicating artery; thus, interventional aneurysm embolization was performed. With stable recovery and improved neurological condition, the patient was discharged for rehabilitation training.
LESSONS
For patients with pituitary apoplexy accompanied by a rapid decrease of neurological conditions, emergency decompression through endoscopic endonasal transsphenoidal resection can achieve satisfactory results. However, with occlusion of the ICA by enlarged pituitary adenoma or pituitary apoplexy, a hidden but rare intracranial aneurysm may be considered when patients are at high risk of such vascular disease as aneurysm, and gentle intraoperative manipulations are required. Performing CTA or digital subtraction angiography before and after surgery can effectively reduce the missed diagnosis of comorbidity and thus avoid life-threatening bleeding events from the accidental rupture of an aneurysm.
... [2,8,9] However, there is only one case report of an iatrogenic rupture of an aneurysm embedded within the pituitary adenoma. [27] Given the fact that routine preoperative MRA investigation are not advocated in the guidelines of management of pituitary adenomas, [5] it can be assumed that some of these injuries are caused by the rupture of an associated aneurysm. [17,21,25] TSS is the preferred method of treatment for GH-secreting tumors, and medical therapy is indicated in cases when contraindications to surgery exist. ...
Background
Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications.
Case Description
We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention.
Conclusions
This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.
... Pituitary adenoma (PA) with coexisting intracranial aneurysm is not uncommon [1][2][3]. Coexistence between an intracranial aneurysm and a pituitary adenoma has been well documented [4][5][6][7][8][9][10]. This association has been reported to range from 3.7% to 7.4%. ...
... However, the great majority of these aneurysms are located outside the tumor itself [11]. The presence of an internal carotid artery (ICA) aneurysm embedded within a pituitary adenoma (PA) located inside the sella turcica has rarely been reported and has been examined in only two case reports [10,12] in the era of endoscopic endonasal transsphenoidal surgery (EETSS). ...
Background: Injury of the internal carotid artery (ICA) in the cavernous portion is one of the most critical complications of transsphenoidal surgery (TSS), especially in cases of coexistence with a pituitary adenoma (PA) and ICA aneurysm.
Case description: We present a rare case of unruptured medial paraclinoid ICA aneurysm (ICA-An) associated with symptomatic nonfunctioning giant PA. After endovascular coil embolization of the unruptured 4-mm saccular medial paraclinoid ICA-An, the patient underwent adenomectomy through an endoscopic endonasal TSS. During the bone resection over the right sellar floor near the right cavernous sinus, a tangle of packed coils in the treated medial paraclinoid ICA-An was observed immediately after a bite of a Kerrison rongeur. The dural layer over the coiled aneurysm had become thin to the point of transparency or complete absence. Careful inspection revealed that the bone hillock was formed by the medial paraclinoid ICA-An. Gross total resection of the adenoma was achieved without vascular injuries related to the coiled aneurysm despite postoperative transient right oculomotor paresis.
Conclusions: This case conveys three important lessons about TSS: 1) coil embolization will manage a medial paraclinoid ICA-An as a sufficient preoperative procedure for TSS; 2) a medial paraclinoid ICA-An can appear directly under the sellar floor as an apparent extradural aneurysm; and; 3) surgeons should take great care in procedures near a coil-embolized medial paraclinoid ICA-An because the aneurysmal wall can be thin to the point of transparency.
... The rare association between a ruptured aneurysm with SAH and pituitary apoplexy [83] as well as the rupture of an aneurysm embedded within a pituitary adenoma with a clinical evidence of epistaxis has also been reported [84]. Suzuki et al. reported a case of pituitary apoplexy caused by an unsuspected aneurysm bleeding into a pituitary adenoma and in which catastrophic intraoperative haemorrhage occurred [85]. ...
Pituitary apoplexy is a rare clinical syndrome due to ischemic or haemorrhagic necrosis of the pituitary gland which complicates 2-12% of pituitary tumours, especially nonfunctioning adenomas. In many cases, it results in severe neurological, ophthalmological, and endocrinological consequences and may require prompt surgical decompression. Pituitary apoplexy represents a rare medical emergency that necessitates a multidisciplinary approach. Modalities of treatment and times of intervention are still largely debated. Therefore, the management of patients with pituitary apoplexy is often empirically individualized and clinical outcome is inevitably related to the multidisciplinary team's skills and experience. This review aims to highlight the importance of a multidisciplinary approach in the management of pituitary apoplexy and to discuss modalities of presentation, treatment, and times of intervention.
