Spontaneous subarachnoid haemorrhage from rupture of an anterior communicating artery aneurysm in a patient with pituitary macroadenoma

Giant Prolactinoma Embedded by Pseudoaneurysm of the Cavernous Carotid Artery Treated with a Tailored Therapeutic Scheme

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.

Subarachnoid Hemorrhage From Rupture of an Undiagnosed Posterior Circulation Aneurysm During Sellar Tumor Surgery

Association between cerebral aneurysms and sellar tumors has been previously reported. Rupture of anterior circulation aneurysms during a transsphenoidal surgery causing massive subarachnoid hemorrhage (SAH) is uncommon, but rupture of a posterior circulation aneurysm is an infrequent event.

We present three cases of SAH secondary to rupture of an undetected posterior circulation aneurysm during transsphenoidal surgery to treat a sellar tumor. The common factor in these cases was the adverse outcome despite treatment. 

The fatal outcome seen in all these cases questions whether to include a (magnetic resonance) MR angiography or (computed tomography) CT angiography during preoperative evaluation for sellar tumors in order to identify inadvertently associated aneurysms.

[Combination of pituitary adenomas and intracranial aneurysms]

The combination of intracranial tumors and asymptomatic brain aneurysms is an urgent problem, since it can significantly affect surgical intervention. Aneurysms are common in patients with meningioma, glioma and pituitary adenoma. According to certain authors, combination of aneurysms with pituitary adenomas is 7 times more common than with other tumors. In these cases, a comprehensive examination of the patient and decision-making on surgical strategy are required. This review is devoted to epidemiology, diagnosis and treatment of patients with a combination of pituitary adenomas and intracranial aneurysms detected intraoperatively or at the preoperative stage. The manuscript is illustrated by cases observed at the Burdenko Neurosurgery Center.

Descent of the anterior communicating artery after removal of pituitary macroadenoma using transsphenoidal surgery

Background:

After removal of pituitary macroadenoma, the anterior communicating artery (AComA) descends toward the original position. However, the process and contributing factors of this descent are not elucidated.

Methods:

This retrospective study included 102 patients who underwent transsphenoidal surgery (TSS) for macroadenomas with maximum diameters of >2 cm. Sequential T2-weighted magnetic resonance images were used to assess the AComA flow void and its distance from the planum sphenoidale before and after TSS. The AComA position in relation to the adenoma was divided into four groups as follows: anterior, anterosuperior, superior, and posterior. The descent was compared to the presence of intratumoral hemorrhage or adenoma extension into the sphenoid sinus.

Results:

One week after TSS, the AComA descent was more pronounced than when originally in the superior position (6.5 ± 3.7 mm vs 4.4 ± 3.5 mm, P < 0.0001). The postoperative descents of the AComA were well correlated with those of residual adenomas only when in the superior position (P = 0.030). The AComA descent was more significant at 1 week (4.4 ± 3.5 mm) than at 1 week to 3 months (0.7 ± 1.0 mm) in all the groups. Both intratumoral hemorrhage and sphenoid sinus extension of adenoma did not affect the AComA descent in each group.

Conclusion:

AComA descent was most influenced when it was superior to the macroadenoma and progressed mostly within 1 week after TSS, probably initiating during TSS. The position of the AComA in relation to a macroadenoma should be considered preoperatively to avoid vascular injury.

Intracranial hemorrhage due to rupture of an anterior communicating artery aneurysm in a patient with pituitary adenoma

The coexistence of pituitary adenoma (PA) and anterior communicating artery aneurysm is extremely rare, making the diagnosis difficult and the treatment challenging. Herein, we present a PA patient with intracranial hemorrhage due to rupture of an anterior communicating artery aneurysm. For the best diagnosis of intracranial aneurysm among PA patients, cranial magnetic resonance together with three-dimensional time-of-flight magnetic resonance angiography are strongly recommended. Previous treatment of the intracranial aneurysm is advisable and essential to avoid possible catastrophic bleeding during the transsphenoidal or microsurgical removal of PA.

Pituitary adenoma apoplexy caused by rupture of an anterior communicating artery aneurysm: case report and literature review

BACKGROUND

Pituitary adenoma combined with intracranial aneurysm is not rare. Some aneurysms are located inside pituitary adenomas, and most do not rupture. Pituitary apoplexy caused by aneurysm rupture is rare and is easily misdiagnosed as simple pituitary adenoma apoplexy.

CASE PRESENTATION

In this study, we report one case of rare pituitary adenoma apoplexy caused by the rupture of an anterior communicating artery aneurysm. The patient was a 49-year-old male who had an untreated pituitary adenoma for 3 years. The patient experienced a sudden headache; computed tomography (CT) and magnetic resonance imaging (MRI) revealed pituitary adenoma apoplexy and significant subarachnoid hemorrhage. Cranial CT angiography (CTA) showed a communicating artery aneurysm. Supratentorial intracranial aneurysm clipping and pituitary adenoma resection were performed. The aneurysm was a ruptured aneurysm located inside the pituitary adenoma. During the surgery, the aneurysm was clipped, and the majority of the tumor was resected. The patient recovered well after the surgery and received radiotherapy.

CONCLUSIONS

This rare case demonstrates that when pituitary adenoma apoplexy is combined with subarachnoid hemorrhage, the possibility of a combined intrasellar aneurysm should be considered. During transsphenoidal tumor resection, aneurysm rupture should be avoided to prevent disastrous consequences.