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

Simultaneous resection of pituitary adenoma and clipping of aneurysm through endoscopic endonasal approach: a case report

Pituitary adenomas and intracranial aneurysms are prevalent neurosurgical conditions, but their simultaneous presence is uncommon, affecting only 0.5%-7.4% of those with pituitary adenomas. The strategy of treating aneurysms endovascularly before removing pituitary adenomas is widely adopted, yet reports on addressing both conditions at once through an endoscopic endonasal approach (EEA) are scarce. We present a case involving a pituitary adenoma coupled with an anterior communicating artery aneurysm. Utilizing the EEA, we excised the adenoma and clipped the aneurysm concurrently. The patient recovered well post-surgery, with follow-up assessments confirming the successful resolution of both the adenoma and aneurysm. We proved the feasibility of the EEA in the treatment of pituitary adenomas with anterior communicating artery aneurysms under specific anatomical relationships and close intraoperative monitoring.

An algorithm for the treatment of concurrent pituitary adenoma and cavernous sinus aneurysm: A systematic review & case report

BACKGROUND

Rarely, Pituitary adenomas (PA) can co-occur with intrasellar or intracavernous aneurysms. There is currently no clear guidance for the management of this dual pathology. We attempt to provide an algorithm to help guide clinical decision making for treatment of PAs co-occurring with adjacent cerebral aneurysms.

METHODS

A comprehensive literature search was conducted following PRISMA guidelines using various databases. Search terms included "(Pituitary Adenoma OR Prolactinoma OR Macroadenoma OR Adenoma) AND (ICA OR Internal Carotid Artery OR paracliniod OR clinoid) Aneurysm AND (Intra-cavernous OR intracavernous OR intrasellar OR Cavernous)."

RESULTS

A total of 24 studies with 24 patients were included. Twelve (50%) patients experienced visual symptoms. Ten patients (42%) had an aneurysm embedded within the adenoma. Fourteen patients (58%) had an aneurysm adjacent to the adenoma. Embedded aneurysms were significantly associated with rupture events.

CONCLUSION

Vision loss is the most pressing determinant of treatment. In the absence of visual symptoms, the aneurysm should be treated first by coil embolization. If not amenable to coiling, place flow diverting stent followed by six months of anticoagulation and antiplatelet therapy. If visual loss is apparent, the adenoma-aneurysm spatial relationship becomes critical. In cases of an adjacent aneurysm, the adenoma should be removed transsphenoidally with extreme care and aneurysm rupture protocols in place. If the aneurysm is embedded within the adenoma, then a BTO is favored with permanent ICA occlusion followed by transsphenoidal resection if adequate collateral supply is demonstrated. If there is inadequate collateral supply, then an open-approach for amenable aneurysms with transcranial adenoma debulking should be performed.

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.

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.

Management of Coincident Pituitary Macroadenoma and Cavernous Carotid Aneurysm: A Systematic Literature Review

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.

Stent-Assisted Coil Embolization of a Basilar Artery Dissecting Aneurysm Involved in Skull Base Chordoma Before Endoscopic Transsphenoidal Transclival Resection

BACKGROUND

Skull base chordomas will occasionally penetrate the clival dura mater and extend into the prepontine cistern, involving the basilar artery. Few reports have described cases of skull base chordoma accompanying a dissecting aneurysm of the basilar artery, and the treatment strategies have remained largely unknown.

CASE DESCRIPTION

A 28-year-old man was referred to our hospital with a complaint of severe headache. A skull base chordoma involving a basilar artery dissecting aneurysm was diagnosed. We initially performed endovascular surgery for the dissecting aneurysm after dual antiplatelet therapy before surgical resection of the tumor, which was successfully achieved without complications. Follow-up angiography 3 months after endovascular surgery disclosed obliteration of the dissecting aneurysm. We then stopped the dual antiplatelet therapy, and performed judicious resection using an endoscopic transclival approach. The residual tumor was treated with radiosurgery. At the last follow-up examination, the patient was stable, and the tumor remained sufficiently controlled.

CONCLUSIONS

We have reported a case of a dissecting aneurysm of the basilar artery with clival chordoma. Our findings suggest that chordoma with intradural vascular encasement has the potential to invade the vessel wall. To avoid rupture of those critical vascular structures, treatment strategies that minimize stress on the involved arteries and offer safe and sufficient surgical resection should be considered.