Clipping of a superior hypophyseal artery aneurysm during endoscopic transnasal removal of a Rathke cleft cyst: a case report

Rathke's cleft cyst discovered with ruptured anterior communicating artery aneurysm: a case report

INTRODUCTION

Rathke's cleft cysts are thought to have a benign clinical outcome apart from associated hypopituitarism and visual defects. Synchronous central nervous system lesions, including pituitary adenoma and intracerebral aneurysms, are rarely reported. Diagnosis of Rathke's cleft cyst after presenting with a subarachnoid hemorrhage due to a ruptured arterial aneurysm is reported only once before.

CASE PRESENTATION

A 33-year-old Sri Lankan female presented with a subarachnoid hemorrhage due to a ruptured anterior communication artery aneurysm. She underwent pterional craniotomy and aneurysm clipping. She was found to have partial cranial diabetes insipidus and hypogonadotropic hypogonadism. She had a cystic lesion occupying enlarged sella turcica with characteristics of a Rathke's cleft cyst. Subsequently, she underwent trans-sphenoidal excision of the sellar lesion. Histology confirmed the diagnosis of Rathke's cleft cyst.

CONCLUSIONS

Rare co-occurrence of a Rathke's cleft cyst and an anterior communicating artery aneurysm would have been missed if subtle manifestations atypical for subarachnoid hemorrhage were not further pursued. This could have led to progressive visual deterioration and hypopituitarism.

Transnasal Resection of an Adrenocorticotropic Hormone-Secreting Adenoma and Clipping of a Paraclinoid Aneurysm: Two-Dimensional Operative Video

Although pituitary adenomas and intracranial aneurysms often coexist,1 the locations of these lesions rarely affect surgical planning. In such cases, however, a simultaneous (rather than staged) approach avoids multiple procedures or delays in treating the dominant pathology. Building on limited prior reports of transnasal aneurysm clipping,2-6 we describe simultaneous transnasal treatment of an adrenocorticotropic hormone-secreting adenoma and a paraclinoid aneurysm in a 35-year-old woman (Video 1). The patient presented with weight gain, cutaneous striae, and fatigue, with endocrinologic testing notable for elevated adrenocorticotropic hormone and midnight salivary/24-hour urinary free cortisol. Imaging demonstrated a possible microadenoma. Petrosal sinus sampling confirmed the diagnosis and left laterality and identified a 3.0 × 2.7 × 2.2 mm left inferomedial paraclinoid internal carotid artery aneurysm with erosion through the bone into the sphenoid sinus. A transnasal approach to both lesions was planned given the proximity of the lesions, the inaccessibility of the aneurysm transcranially, and the likelihood of needing a stent or flow diverter with endovascular treatment that would delay treatment of the Cushing disease. An endoscopic endonasal approach was used for uneventful adenoma resection. The medial wall of the cavernous sinus was opened sharply to expose the carotid artery and aneurysm. Clipping was completed during an adenosine pause despite limited degrees of freedom. Postoperatively, the patient developed transient diabetes insipidus and hydrocortisone dependence but was neurologically intact and eupituitary on follow-up. With sufficient transnasal and vascular surgical experience, transnasal clipping of aneurysms can be safely performed in very selected cases. The patient consented to the procedures and publication.

Endoscopic endonasal approach for simultaneously treating a pituitary adenoma coexisting with a paraclinoid aneurysm: illustrative case

BACKGROUND

There is a certain incidence of pituitary adenomas coexisting with intracranial aneurysms, but a concurrent therapeutic strategy of tumor removal and aneurysm clipping via endoscopic endonasal approach is rarely reported. The indications and limitations of endoscopic endonasal approach surgery for this type of lesions are worth discussing.

OBSERVATIONS

The case of a pituitary tumor coexisting with a paraclinoid aneurysm was reviewed. Using an endoscopic endonasal approach, the pituitary adenoma was completely excised with extrapseudocapsular separation technique, the aneurysm was clipped at the same time, and the skull base defect was reconstructed in multilayer fashion. No tumor recurrence was found, and aneurysm clipping was complete at the 6-month follow-up after surgery.

LESSONS

For patients harboring a pituitary adenoma with a selected paraclinoid aneurysm, simultaneous tumor resection and aneurysm clipping via endoscopic endonasal approach are feasible. This strategy has the advantages of saving medical resources, promoting the patient’s rapid postoperative recovery, and reducing possible antiplatelet therapy after interventional therapy. However, surgery needs to strictly follow the indications in experienced hands, and the therapeutic effect needs to be verified by more cases and longer follow-up results.

Combined Endoscopic Endonasal and Bilateral Subfrontal Approach for a Nonfunctioning Pituitary Adenoma Associated with an Internal Carotid Artery-Superior Hypophyseal Artery Aneurysm

BACKGROUND

An aneurysm embedded in a pituitary adenoma is rare, and treatment for both the aneurysm and pituitary adenoma is complex and controversial.

CASE DESCRIPTION

A 53-year-old woman presented with a visual field defect. Magnetic resonance imaging showed a pituitary adenoma and coexistence of an aneurysm located at the orifice of the superior hypophyseal artery (SHA) from the internal carotid artery (ICA). The aneurysm was embedded in the pituitary adenoma; therefore, obliteration of the aneurysm was needed prior to tumor removal to prevent intraoperative rupture of the aneurysm. Although endovascular coil embolization was tried first, it was not successful. A combined endoscopic endonasal approach and transcranial approach was performed for simultaneous tumor removal and aneurysm clipping. A bilateral subfrontal approach was selected for aneurysm clipping because, using this approach, the parent artery was safely controlled from the ipsilateral trajectory, whereas exposure and clipping of the aneurysm were easily done from the contralateral trajectory. Additionally, the supine head position without rotation is comfortable for endoscopic endonasal surgery. The tumor was totally removed, and the aneurysm was safely and completely obliterated with a clip. The patient's postoperative course was uneventful, and her visual disturbance improved.

CONCLUSIONS

A combined endoscopic endonasal and bilateral subfrontal approach is effective for a pituitary adenoma associated with an ICA-SHA aneurysm.