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Cifuentes-Lobelo H, Castañeda-Duarte MA, Ruiz-Diaz D, Cortes-Lozano W. Ectopic Intrasphenoidal Growth Hormone Releasing Pituitary Adenoma Associated with an Intracranial Aneurysm. Asian J Neurosurg 2024; 19:520-525. [PMID: 39205895 PMCID: PMC11349417 DOI: 10.1055/s-0042-1757434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Pituitary adenomas are a type of of the most frequent intracranial tumors. These tumors can extend outside the sella, but very rarely originate ectopically to the sellar region. A 71-year-old patient presented to our institution, with prior clinical history of noncontrolled arterial hypertension and new-onset high-intensity pulsatile headache. Upon suspicion of a hypertensive emergency with probable brain compromise, a nonenhanced computed tomography of the head was performed. A mass within the sphenoid sinus was found. Endocrinological workup demonstrated a significant elevation of the growth hormone. As an incidental finding, a brain aneurysm was evidenced, which was treated endovascularly prior to the mass treatment. Subsequently, the patient successfully underwent a gross total resection through an endonasal transsphenoidal approach. Histopathological results were consistent with a pituitary ectopic adenoma. A postoperative improvement in levels of somatomedin C was documented postoperatively.
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Affiliation(s)
- Hernando Cifuentes-Lobelo
- Department of Neurosurgery, Hospital Infantil Universitario de San José - Sociedad de Cirugía de Bogotá, Fundación Universitaria de Ciencias de la Salud, Colombia
| | - Marcelo A Castañeda-Duarte
- Department of Neurosurgery, Hospital Infantil Universitario de San José - Sociedad de Cirugía de Bogotá, Fundación Universitaria de Ciencias de la Salud, Colombia
| | - Diego Ruiz-Diaz
- Medical School, Hospital Infantil Universitario de San José - Sociedad de Cirugía de Bogotá, Fundación Universitaria de Ciencias de la Salud, Colombia
| | - William Cortes-Lozano
- Department of Neurosurgery, Hospital Infantil Universitario de San José - Sociedad de Cirugía de Bogotá, Fundación Universitaria de Ciencias de la Salud, Colombia
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Villalobos-Diaz R, Marian-Magaña R, Sangrador-Deitos MV, Vazquez-Gregorio R, Rodriguez-Hernandez LA, Lopez-Valencia G, Aragon-Arreola JF, Lara-Olivas JA, Guinto-Nishimura GY, Eguiluz-Melendez AG, Gomez-Amador JL. Surgical treatment of pituitary neuroendocrine tumors with coexisting intracranial lesions: A case series and review of the literature. Surg Neurol Int 2024; 15:96. [PMID: 38628542 PMCID: PMC11021101 DOI: 10.25259/sni_22_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/13/2024] [Indexed: 04/19/2024] Open
Abstract
Background Pituitary neuroendocrine tumors (PitNETs) are a diverse group of benign neoplasms that account for a significant proportion of intracranial tumors (13%). The coexistence of PitNET with other intracranial lesions, such as meningiomas and intracranial aneurysms, has been constantly reported in the literature; yet, the pathophysiological mechanisms remain unknown, and the appropriate management is controversial. This study aims to describe the clinical characteristics, surgical treatment, and outcomes of patients with PitNET with coexisting intracranial lesions in a single healthcare center. Methods A retrospective analysis was conducted on 12 patients who underwent surgical treatment for PitNET and another intracranial lesion at our single tertiary referral center over 15 years from January 2008 to May 2023. Results Among these coexisting lesions, aneurysms were the most commonly found (41.67%), followed by meningiomas (33.33%). Surgical intervention for both lesions was performed in a single-stage procedure for most cases (75%), employing transcranial, endoscopic endonasal, and combined approaches. We found low preoperative Karnofsky Performance Scale scores in three patients, with significant differences in functional outcomes. Conclusion These findings contribute to the limited knowledge about PitNET coexisting with other intracranial lesions and emphasize the importance of patient-tailored, multidisciplinary management in these unusual scenarios.
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Affiliation(s)
- Rodolfo Villalobos-Diaz
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Ricardo Marian-Magaña
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Rafael Vazquez-Gregorio
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - German Lopez-Valencia
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | | | | | - Aldo Gabriel Eguiluz-Melendez
- Department of Neurosurgery, Salvador Zubirán National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Juan Luis Gomez-Amador
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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Wan XC, Chen YX, Xiong Y, Wu J, Chen SS, Tang B, Hong T, Wu X. Perisellar Tumor Coexisting with Unruptured Cerebral Aneurysm: Single-Stage or Staged Surgery? World Neurosurg 2023; 180:e46-e55. [PMID: 37544600 DOI: 10.1016/j.wneu.2023.07.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE The coexistence of perisellar tumors and intracranial aneurysms was previously considered a rare phenomenon. In this study, we introduce our experience with surgical strategies for the treatment of such coexisting pathologies. METHODS This retrospective study reviews the medical records and intraoperative videos of patients with coexisting pathologies of perisellar tumors and aneurysms from Nov 2017 to Oct 2022. RESULTS Our study involved 20 patients, including 9 males and 11 females. Three patients selected the single-stage endoscopic endonasal approach (EEA), including one with a type of MP trigeminal schwannoma with an anterior communicating aneurysm, 1 with a pleomorphic xanthoastrocytoma with a left internal carotid artery paraclinoid aneurysm, and 1 with a recurrent pituitary adenoma with a right internal carotid artery paraclinoid aneurysm. Thirteen patients chose tumor resection first through the EEA with embolization or aneurysm conservation. There were also 2 patients with irregularly shaped aneurysms who chose embolization before tumor resection. All tumors were completely removed, with only a few patients experiencing recurrence and postoperative complications, and the follow-up of the aneurysms was also stable. There were also 2 patients who chose conservative management for both tumors and aneurysms, but unfortunately, one of them suffered from aneurysm rupture and eventually died. No cerebrospinal fluid rhinorrhea, severe intracranial infection, or surgical-related hemorrhage was found in any patients. CONCLUSIONS Staged surgery or conservative treatment for aneurysms can be considered a safe and effective strategy for the treatment of coexisting pathologies. However, in very selected cases, the single-stage EEA can be used as part of a comprehensive treatment for such coexisting pathologies.
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Affiliation(s)
- Xi Chen Wan
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yu Xing Chen
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ye Xiong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jie Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shan Si Chen
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China.
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Holdaway M, Huda S, D'Amico RS, Boockvar JA, Langer DJ, McKeown A, Ben-Shalom N. An algorithm for the treatment of concurrent pituitary adenoma and cavernous sinus aneurysm: A systematic review & case report. J Clin Neurosci 2023; 117:46-53. [PMID: 37757653 DOI: 10.1016/j.jocn.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/30/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
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.
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Affiliation(s)
- Matthew Holdaway
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra New York, NY, United States; Albany Medical College, Albany, NY, United States.
| | - Shayan Huda
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra New York, NY, United States; CUNY School of Medicine, New York City, NY, United States
| | - Randy S D'Amico
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra New York, NY, United States
| | - John A Boockvar
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra New York, NY, United States
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra New York, NY, United States
| | - Amy McKeown
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra New York, NY, United States
| | - Netanel Ben-Shalom
- Department of Neurosurgery, Lenox Hill Hospital/Donald and Barbara Zucker School of Medicine at Hofstra New York, NY, United States
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Li L, Ding G, Zhang L, Luo H, Davoodi-Bojd E, Li Q, Chopp M, Zhang ZG, Jiang Q. Glymphatic transport is reduced in rats with spontaneous pituitary tumor. Front Med (Lausanne) 2023; 10:1189614. [PMID: 37601793 PMCID: PMC10436560 DOI: 10.3389/fmed.2023.1189614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background and objective Pituitary tumor in patients induces adverse alterations in the brain, accompanied by cognitive deficits. Dysfunction of glymphatic waste clearance results in accumulation of neurotoxic products within the brain, leading to cognitive impairment. However, the status of glymphatic function in the brain with pituitary tumor is unknown. Using magnetic resonance imaging (MRI) and an advanced mathematical modeling, we investigated the changes of glymphatic transport in the rats carrying spontaneous pituitary tumor. Methods Rats (22-24 months, female, Wistar) with and without pituitary tumor (n = 7/per group) underwent the identical experimental protocol. MRI measurements, including T2-weighted imaging and dynamic 3D T1-weighted imaging with intracisternal administration of contrast agent, were performed on each animal. The contrast-induced enhancement in the circle of Willis and in the glymphatic influx nodes were observed on the dynamic images and verified with time-signal-curves (TSCs). Model-derived parameters of infusion rate and clearance rate that characterize the kinetics of glymphatic tracer transport were evaluated in multiple representative brain regions. Results Our imaging data demonstrated a higher incidence of partially enhanced circle of Willis (86 vs. 14%; p < 0.033) and a lower incidence of enhancement in glymphatic influx nodes of pituitary (71 vs. 100%) and pineal (57 vs. 86%) recesses in the rats with pituitary tumor than in the rats with normal appearance of pituitary gland, indicating an intensification of impaired peri-vascular pathway and impeded glymphatic transport due to the presence of pituitary tumor. Consistently, our kinetic modeling and regional cerebral tissue quantification revealed significantly lower infusion and clearance rates in all examined regions in rats with spontaneous pituitary tumor than in non-tumor rats, representing a suppressed glymphatic transport in the brain with pituitary tumor. Conclusion Our study demonstrates the compromised glymphatic transport in the rat brain with spontaneous pituitary tumor. The reduced efficiency in cerebral waste clearance increases the risk for neurodegeneration in the brain that may underlie the cognitive impairment commonly seen in patients with pituitary tumors.
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Affiliation(s)
- Lian Li
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Guangliang Ding
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Li Zhang
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Hao Luo
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | | | - Qingjiang Li
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Michael Chopp
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
- Department of Physics, Oakland University, Rochester, MI, United States
| | - Zheng Gang Zhang
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Quan Jiang
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
- Department of Physics, Oakland University, Rochester, MI, United States
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Spille DC, Vorona E, Catalino MP, Reuter G, Beckers A, Holling M, Fava A, Stummer W, Laws ER, Suero-Molina E. Vascular anomalies in patients with growth hormone-secreting pituitary adenomas: illustrative case report and systematic review of the literature. Pituitary 2023; 26:132-143. [PMID: 36508085 PMCID: PMC9908726 DOI: 10.1007/s11102-022-01291-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Endonasal resection is the first-line treatment for patients harboring growth hormone (GH)-secreting pituitary adenomas. The complexity of the parasellar neurovascular structures makes pre-operative diagnostic imaging essential to understanding the anatomy of this region. We aimed to describe vascular anomalies in acromegalic patients and emphasize their relevance for surgery and preoperative planning. METHODS A systematic review following the PRISMA statement was performed in July 2021. RESULTS Thirty-three studies were evaluated. Elevated GH and insulin-like growth factor-1 (IGF-1) levels are linked to the occurrence of cardiovascular risk factors. This is attributed to endothelial dysfunction, mainly caused by changes in flow-mediated dilatation (FMD), which is probably the main cause of vascular anomalies in acromegaly. The occurrence of protrusions of the internal carotid artery (ICA) (35-53%), a narrow intercarotid distance, and an asymmetrical course was described. In 13-18% of acromegalic patients, the presence of an intracerebral aneurysm could be reported (incidence in the general population:0.8-1.3%). The selected studies were however performed with a small patient sample (range:1-257). We present a case report of a 57y/o male patient with anomalies of the ICA ("kissing carotid arteries") harboring a GH-secreting adenoma, which was resected via an endoscopic endonasal approach. CONCLUSIONS There is an association between acromegaly and endothelial dysfunction, which increases cardiovascular risk factors and vascular anomalies. Preoperative vascular imaging, e.g., CT angiography, should be implemented as a standard to identify patients at risk and estimate surgical morbidity. However, no evidence-based recommendations exist so far, so future studies are necessary.
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Affiliation(s)
- Dorothee Cäcilia Spille
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Elena Vorona
- Department of Medicine B of Gastroenterology, Hepatology, Endocrinology and Clinical Infectiology Division for Endocrinology and Diabetes, 48149, Münster, Germany
| | | | - Gilles Reuter
- Department of Neurosurgery, University Hospital of Liège, Liège, Belgium
| | - Albert Beckers
- Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Markus Holling
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Arianna Fava
- Department of Neurosurgery, I.R.C.C.S. Neuromed, Pozzilli, IS, Italy
| | - Walter Stummer
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Eric Suero-Molina
- Department of Neurosurgery, University Hospital of Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
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Mercuri V, Armocida D, Paglia F, Patrizia G, Santoro A, D'Angelo L. Giant Prolactinoma Embedded by Pseudoaneurysm of the Cavernous Carotid Artery Treated with a Tailored Therapeutic Scheme. J Neurosci Rural Pract 2022; 13:358-369. [PMID: 35945997 PMCID: PMC9357472 DOI: 10.1055/s-0042-1749662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Valeria Mercuri
- Endocrinology Unit, Department of Experimental Medicine, 'Sapienza' University of Rome, Rome, Italy
| | - Daniele Armocida
- Department of Human Neurosciences, Neurosurgery, 'Sapienza' University of Rome, Rome, Italy
| | - Francesco Paglia
- Department of Human Neurosciences, Neurosurgery, 'Sapienza' University of Rome, Rome, Italy
| | - Gargiulo Patrizia
- Endocrinology Unit, Department of Experimental Medicine, 'Sapienza' University of Rome, Rome, Italy
| | - Antonio Santoro
- Department of Human Neurosciences, Neurosurgery, 'Sapienza' University of Rome, Rome, Italy
| | - Luca D'Angelo
- Department of Human Neurosciences, Neurosurgery, 'Sapienza' University of Rome, Rome, Italy
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Mondragón-Soto MG, Villanueva-Castro E, Tovar-Romero LA, Aragón-Arreola JF, Sangrador-Deitos MV, Cano-Velázquez G, Villanueva-Solórzano PL, Gómez-Amador JL. Magnetic resonance imaging finding of coexistence of bilateral paraclinoid aneurysms in a patient with a nonfunctioning macroadenoma, simultaneous resection, and clipping: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21720. [PMID: 36273858 PMCID: PMC9379769 DOI: 10.3171/case21720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/28/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Michel G. Mondragón-Soto
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
| | - Eliezer Villanueva-Castro
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
| | - Leoncio A. Tovar-Romero
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
| | - Jorge F. Aragón-Arreola
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
| | - Marcos V. Sangrador-Deitos
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
| | - Gerardo Cano-Velázquez
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
| | - Pedro L. Villanueva-Solórzano
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
| | - Juan L. Gómez-Amador
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía “Dr. Manuel Velasco Suárez,” Mexico City, Mexico
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Nene A, Hong CS, McGuone D, Matouk CC, Omay SB. Staged endovascular treatment of a coexisting parasellar aneurysm and endoscopic resection of a pituitary macroadenoma: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21699. [PMID: 36130536 PMCID: PMC9379633 DOI: 10.3171/case21699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Intracranial aneurysms and pituitary adenomas are relatively common pathologies that, in rare instances, may concurrently present. Their management poses considerable clinical and technical challenges.
OBSERVATIONS
The authors present a case of a 66-year-old female patient with a fusiform aneurysm of the left internal carotid artery associated with a symptomatic pituitary macroadenoma that had been causing visual deficits for the past several years. She underwent successful placement of flow diverter stents across her aneurysm, followed by routine dual antiplatelet therapy to maintain stent patency. She underwent frequent serial radiographic, endocrine, and ophthalmological evaluations during this time to ensure stability of her pituitary adenoma. Following confirmation of aneurysm obliteration and subsequent de-escalation of antiplatelet medications to aspirin monotherapy, her tumor was subsequently resected via an endoscopic endonasal approach in a delayed fashion.
LESSONS
The authors review the literature regarding management of these concurrent pathologies and describe the aspects of the case that led them to their chosen treatment strategy. An algorithm is proposed regarding the management of parasellar aneurysms with a concurrent diagnosis of pituitary tumor pathology.
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Affiliation(s)
| | | | - Declan McGuone
- Pathology, Yale School of Medicine, New Haven, Connecticut
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10
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Piper KJ, Karsy M, Barton B, Rabinowitz M, Rosen MR, Nyquist GG, Evans JJ, Tjoumakaris S, Farrell CJ. Management of Coincident Pituitary Macroadenoma and Cavernous Carotid Aneurysm: A Systematic Literature Review. J Neurol Surg Rep 2021; 82:e25-e31. [PMID: 34603930 PMCID: PMC8481005 DOI: 10.1055/s-0041-1735904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/26/2021] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Keenan J Piper
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Michael Karsy
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Blair Barton
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Mindy Rabinowitz
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Marc R Rosen
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Gurston G Nyquist
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
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11
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Chernov IV, Kutin MA, Kheyreddin AS, Konovalov AN, Shekhtman OD, Eliava SS, Kalinin PL. [Combination of pituitary adenomas and intracranial aneurysms]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:94-103. [PMID: 33560625 DOI: 10.17116/neiro20218501194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- I V Chernov
- Burdenko Neurosurgery Center, Moscow, Russia
| | - M A Kutin
- Burdenko Neurosurgery Center, Moscow, Russia
| | | | | | | | | | - P L Kalinin
- Burdenko Neurosurgery Center, Moscow, Russia
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12
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Rajagopal N, Thakar S, Hegde V, Aryan S, Hegde AS. Morphometric Alterations of the Sphenoid Ostium and other Landmarks in Acromegaly: Anatomical Considerations and Implications in Endoscopic Pituitary Surgery. Neurol India 2020; 68:573-578. [PMID: 32643665 DOI: 10.4103/0028-3886.288996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background The sphenoid ostium (SO) is an important landmark for the endoscopic surgeon. Changes in size and position of the SO and variations in other skull base landmarks in acromegalics have not been adequately evaluated. Aims The authors evaluated the morphometry and location of the SO and other landmarks in acromegaly and compared these findings with those in nonfunctioning pituitary adenomas (NFPAs). Methods In this retrospective case-control study, the dimensions and location of the SO and other skull base landmarks were radiologically evaluated in 18 patients with growth hormone (GH)-secreting adenomas. These findings were analyzed in relation to preoperative GH levels and compared with 18 age- and sex-matched controls with NFPAs. Results The dimensions of the SO were significantly larger in the GH-adenoma group (P < 0.05). The SO was further from the midline (P = 0.04) and closer to the sphenopalatine foramen (SPF) (P = 0.02) in the GH-adenoma group, and this finding correlated with increasing preoperative GH levels. Acromegalics demonstrated larger intracavernous carotid diameters (P = 0.05) and smaller intercarotid distances than the patients with NFPAs (P = 0.02). Conclusion The SO is larger and located higher up in the sphenoid face and closer to the SPF in patients with GH adenomas. Increasing GH levels in these patients correlate with the upward and lateral displacement of the SO. These patients demonstrate larger intracavernous carotid diameters and smaller intercarotid distances than patients with NFPAs. These morphological alterations are of particular relevance to the pituitary surgeon.
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Affiliation(s)
- Niranjana Rajagopal
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - Sumit Thakar
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - Vinay Hegde
- Department of Radiodiagnosis, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - Saritha Aryan
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
| | - Alangar S Hegde
- Department of Neurological Sciences, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
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Kino H, Ito Y, Akutsu H, Tanaka S, Hara T, Ishikawa E, Miyamoto H, Matsumaru Y, Matsumura A. Combined Endoscopic Endonasal and Bilateral Subfrontal Approach for a Nonfunctioning Pituitary Adenoma Associated with an Internal Carotid Artery-Superior Hypophyseal Artery Aneurysm. World Neurosurg 2019; 134:297-301. [PMID: 31698130 DOI: 10.1016/j.wneu.2019.10.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Hiroyoshi Kino
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yoshiro Ito
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Hiroyoshi Akutsu
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Shuho Tanaka
- Department of Otolaryngology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Takuma Hara
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hidetaka Miyamoto
- Department of Otolaryngology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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14
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Maffei P, Dassie F, Wennberg A, Parolin M, Vettor R. The Endothelium in Acromegaly. Front Endocrinol (Lausanne) 2019; 10:437. [PMID: 31396153 PMCID: PMC6667653 DOI: 10.3389/fendo.2019.00437] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/18/2019] [Indexed: 12/12/2022] Open
Abstract
Growth hormone (GH) and insulin like growth factor-1 (IGF-1) excess induce well-known deleterious effects on the cardiovascular system, especially after long-term exposition. Acromegaly, a condition of chronic GH and IGF-1 hypersecretion, is frequently associated to cardiovascular complications, although recent studies have shown a reduction in the prevalence of these comorbidities in well-controlled patients and a mortality risk similar to normal aging population. Many factors could contribute to the increased cardiovascular risk of acromegaly patients. Among these factors, the endothelium plays a key role in the pathogenesis of atherosclerotic plaques and could be considered an early marker of atherosclerosis and cardiovascular dysfunction. In this review we examined the relationship between GH/IGF-1 excess and the endothelium, from basic studies to clinical evidence. Many studies involving various arterial districts (microvascular arteries of retina, kidney and brain, and major vessels as carotid and aorta) showed that GH/IGF-1 excess promotes endothelial dysfunction via several different mechanisms. Increased endothelial proliferation, dysfunction of endothelial progenitor cells, increased oxidative stress, and compromised oxidative defenses are the main factors that are associated with endothelial dysfunction. In the general population, these alterations are associated with the development of atherosclerosis with an increased incidence of coronary artery disease and cerebrovascular complications. However, in acromegaly this is still a debated issue, despite the presence of many pro-atherogenic factors and comorbidities, such as hypertension, diabetes, sleep apnoea, and metabolic syndrome. Preclinical markers of atherosclerosis as arterial intima media thickness, pulse wave velocity and flow mediated dilation seem to be impaired in acromegaly and partly mediated by the endothelium dysfunction. In conclusion, the pathophysiology of endothelial dysfunction in the condition of GH and IGF-1 excess remains a crucial area of investigation to fully dissect the association of acromegaly with cardiovascular disease complications.
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Affiliation(s)
- Pietro Maffei
- Clinica Medica 3, Department of Medicine (DIMED), Padua University Hospital, Padua, Italy
- *Correspondence: Pietro Maffei
| | - Francesca Dassie
- Clinica Medica 3, Department of Medicine (DIMED), Padua University Hospital, Padua, Italy
| | - Alexandra Wennberg
- Clinica Neurologica, Department of Neurosciences (DNS), Padua University Hospital, Padua, Italy
| | - Matteo Parolin
- Clinica Medica 3, Department of Medicine (DIMED), Padua University Hospital, Padua, Italy
| | - Roberto Vettor
- Clinica Medica 3, Department of Medicine (DIMED), Padua University Hospital, Padua, Italy
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15
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Raper DM, Ding D, Evans E, Starke RM, Crowley RW, Liu KC, Oldfield EH, Jane JA. Clinical Features, Management Considerations and Outcomes in Case Series of Patients with Parasellar Intracranial Aneurysms Undergoing Anterior Skull Base Surgery. World Neurosurg 2017; 99:424-432. [DOI: 10.1016/j.wneu.2016.11.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
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16
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Satyarthee GD, Raheja A. Unruptured Internal Carotid Artery Aneurysm Associated with Functional Pituitary Adenoma: A True Association. Asian J Neurosurg 2017; 12:701-704. [PMID: 29114287 PMCID: PMC5652099 DOI: 10.4103/1793-5482.215760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Detection of incidental intracranial aneurysm on neuroimaging can be associated with pituitary adenoma; however, such association is extremely rare. However, aneurysm with extension into the sella is extremely rare, and increases the risk of inadvertent intraoperative rupture, if trans-sphenoidal decompression is attempted either using endoscopic or microscopic surgical approach. Hanak et al. in a literature review of intrasellar noniatrogenic aneurysms over PubMed search in 2012 could only collect 31 studies, of which only eight cases had pituitary adenoma associated with aneurysm extending into sella. Authors report an interesting case of 52-year-old male diagnosed as case of acromegaly, was put on dopamine agonist, bromocriptine and responding well to therapy, however the magnetic resonance imaging raised suspicion of vascular pathology, and underwent digital subtraction angiography at our center revealed presence of right supracliniod internal carotid aneurysm, which was coiled using endovascular technique with resultant good outcome.
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Affiliation(s)
| | - Amol Raheja
- Department of Neurosurgery, Neurosciences Centre, AIIMS, New Delhi, India
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17
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Abstract
The sellar region is a tiny anatomic compartment in which many lesions and developmental diseases can be found. If pituitary adenomas represent most of the sellar mass, it is important to recognize other pathologic conditions before any surgical procedure, because the optimal treatment may differ considerably from one lesion to another. A careful clinical evaluation followed by neuroimaging studies and an endocrinologic and ophtalmologic workup will lead, in most cases, to a diagnosis with near certainty. This article provides an overview of sellar diseases with emphasis on their most useful characteristics for clinical practice.
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Affiliation(s)
- Damien Bresson
- Neurosurgery Department, Assistance Publique-Hôpitaux de Paris, 2 rue Ambroise Paré, Paris 75010, France
| | - Philippe Herman
- ENT Department, Lariboisière Hospital, Université Paris VII - Diderot, 2 rue Ambroise Paré, Paris 75010, France
| | - Marc Polivka
- Department of Pathology, Lariboisiere Hospital, 2 rue Ambroise Paré, Paris 75010, France
| | - Sébastien Froelich
- Neurosurgery Department, Assistance Publique-Hôpitaux de Paris, Université Paris VII - Diderot, 2 rue Ambroise Paré, Paris 75010, France.
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18
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Choi HS, Kim MS, Jung YJ, Kim OL. Incidental Superior Hypophygeal Artery Aneurysm Embedded within Pituitary Adenoma. J Korean Neurosurg Soc 2013; 54:250-2. [PMID: 24278658 PMCID: PMC3836936 DOI: 10.3340/jkns.2013.54.3.250] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 05/28/2013] [Accepted: 08/19/2013] [Indexed: 11/29/2022] Open
Abstract
Intra-cranial aneurysm can be incidental findings in patients with pituitary adenomas, and are usually located outside the pituitary region. However, the coexistence of intrasellar (not intracranial) aneurysms with pituitary adenomas is extremely rare. We report a patient with an incidental superior hypophygeal aneurysm embedded within a non-functional pituitary adenoma which was treated by transsphenoidal surgery after endovascular coil embolization.
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Affiliation(s)
- Hong-Seok Choi
- Department of Neurosurgery, Yeungnam University College of Medicine, Daegu, Korea
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19
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Endoscopic extracapsular removal of pituitary adenoma: the importance of pretreatment of an adjacent unruptured internal carotid artery aneurysm. Case Rep Neurol Med 2012; 2012:891847. [PMID: 23119196 PMCID: PMC3483703 DOI: 10.1155/2012/891847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 10/02/2012] [Indexed: 11/17/2022] Open
Abstract
The presence of an intracranial aneurysm together with a pituitary adenoma presents tremendous risk of subarachnoid hemorrhage, during transsphenoidal surgery, particularly when the aneurysm lies near the operative field. A left supraclinoid internal carotid artery aneurysm and a clinically nonfunctioning pituitary adenoma coexisted in a 57-year-old woman. Initially, the aneurysm was treated by endovascular coil placement, and then the patient underwent pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach. Pseudocapsule-based extracapsular total resection was safely performed, because of the extirpated risk of rupture of the coil-treated aneurysm. Recently, transsphenoidal pseudocapsule-based extracapsular resection approach for pituitary adenomas provides a more effective and safe alternative compared to the traditional intracapsular one because of its higher tumor removal and remission rates and lower recurrence rate. Compared with conventional subcapsular removal, pseudocapsule-based extracapsular resection has more risks of aneurysmal rupture that is located adjacent to pituitary adenoma. Thus, in a patient having a cerebral aneurysm with the proximity to the operative field, the cerebral aneurysm should be first treated with endovascular coil placement or direct surgical procedure; subsequently, pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach should be performed.
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20
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Hanak BW, Zada G, Nayar VV, Thiex R, Du R, Day AL, Laws ER. Cerebral aneurysms with intrasellar extension: a systematic review of clinical, anatomical, and treatment characteristics. J Neurosurg 2012; 116:164-78. [DOI: 10.3171/2011.9.jns11380] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intrasellar aneurysms are rare lesions that often mimic pituitary tumors, potentially resulting in catastrophic outcomes if they are not appropriately recognized. The authors aimed to characterize the clinical and anatomical details of this poorly defined entity in the modern era of neuroimaging and open/endovascular neurosurgery.
Methods
A PubMed literature review was conducted to identify all studies reporting noniatrogenic aneurysms with intrasellar extension, as confirmed by CT or MR imaging and angiography. Clinical, anatomical, and treatment characteristics were analyzed.
Results
Thirty-one studies reporting 40 cases of intrasellar aneurysms were identified. Six patients (15%) presented with aneurysmal rupture. Patients with unruptured aneurysms presented with the following signs and symptoms: headache (61%), visual field cuts/decreased visual acuity (61%), endocrinopathy (57%), symptomatic hyponatremia (21%), and cranial nerve paresis (other than optic nerve) (18%). The most common endocrine abnormalities were hyperprolactinemia and hypogonadism. Eight aneurysms (20%) were diagnosed in conjunction with a pituitary adenoma. Aneurysms could be categorized into 2 primary anatomical groups as follows: 1) cavernous/clinoid segment internal carotid artery (ICA) (infradiaphragmatic) aneurysms with medial extension into the sella; and 2) suprasellar (supradiaphragmatic) aneurysms originating from the ophthalmic segment of the ICA or from the anterior communicating artery, with inferomedial extension into the sella. The mean diameters of infradiaphragmatic and supradiaphragmatic aneurysms were 14.5 and 21.8 mm, respectively. Infradiaphragmatic aneurysms were much more likely to present with endocrinopathy, whereas supradiaphragmatic ones presented more commonly with visual disturbances. Aneurysms with infradiaphragmatic growth were generally treated using either endovascular techniques or surgical trapping and bypass, while supradiaphragmatic aneurysms were more often treated by surgical clipping.
Conclusions
Aneurysms with intrasellar extension typically present due to mass effect on surrounding structures, and they can be classified as infradiaphragmatic cavernous or clinoid segment ICA aneurysms, or supradiaphragmatic ophthalmic ICA or anterior communicating artery aneurysms. Varying approaches exist for treating these complex aneurysms, and intervention strategies depend substantially on the anatomical subtype.
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Affiliation(s)
- Brian W. Hanak
- 1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gabriel Zada
- 2Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Vikram V. Nayar
- 3Department of Neurosurgery, Georgetown University Hospital, Washington, DC; and
| | - Ruth Thiex
- 1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- 1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arthur L. Day
- 4Department of Neurosurgery, University of Texas Medical School at Houston, Texas
| | - Edward R. Laws
- 1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Zada G, Cavallo LM, Esposito F, Fernandez-Jimenez JC, Tasiou A, De Angelis M, Cafiero T, Cappabianca P, Laws ER. Transsphenoidal surgery in patients with acromegaly: operative strategies for overcoming technically challenging anatomical variations. Neurosurg Focus 2010; 29:E8. [PMID: 20887133 DOI: 10.3171/2010.8.focus10156] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECT In addition to difficulties with anesthetic and medical management, transsphenoidal operations in patients with longstanding acromegaly are associated with inherent intraoperative challenges because of anatomical variations that occur frequently in these patients. The object of this study was to review the overall safety profile and anatomical/technical challenges associated with transsphenoidal surgery in patients with acromegaly. METHODS The authors performed a retrospective analysis of 169 patients who underwent endoscopic transsphenoidal operations for growth hormone-secreting adenomas to assess the incidence of surgical complications. A review of frequently occurring anatomical challenges and operative strategies employed during each phase of the operation to address these particular issues was performed. RESULTS Of 169 cases reviewed, there was no perioperative mortality. Internal carotid artery injury occurred in 1 patient (0.6%) with complex sinus anatomy, who remained neurologically intact following endovascular unilateral carotid artery occlusion. Other complications included: significant postoperative epistaxis (5 patients [3%]), transient diabetes insipidus (5 patients [3%]), delayed symptomatic hyponatremia (4 patients [2%]), CSF leak (2 patients [1%]), and pancreatitis (1 patient [0.6%]). Preoperative considerations in patients with acromegaly should include a cardiopulmonary evaluation and planning regarding intubation and other aspects of the anesthetic technique. During the nasal phase of the transsphenoidal operation, primary challenges include maintaining adequate visualization and hemostasis, which is frequently compromised by redundant, edematous nasal mucosa and bony hypertrophy of the septum and the nasal turbinates. During the sphenoid phase, adequate bony removal, optimization of working space, and correlation of imaging studies to intraoperative anatomy are major priorities. The sellar phase is frequently challenged by increased sellar floor thickness, distinct patterns of tumor extension and bony invasion, and anatomical variations in the caliber and course of the internal carotid artery. Specific operative techniques for addressing each of these intraoperative challenges are discussed. CONCLUSIONS Transsphenoidal surgery in patients with longstanding acromegaly frequently poses greater challenges than operations for other types of sellar lesions, yet these challenges may be safely and effectively overcome with the anticipation of specific issues and implementation of various intraoperative techniques.
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Affiliation(s)
- Gabriel Zada
- Department of Neurosurgery, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA.
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Berker M, Aghayev K, Saatci I, Palaoğlu S, Onerci M. Overview of vascular complications of pituitary surgery with special emphasis on unexpected abnormality. Pituitary 2010; 13:160-7. [PMID: 19728100 DOI: 10.1007/s11102-009-0198-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Arterial bleeding during transsphenoidal surgery for pituitary adenoma is known complication. This usually happens due to rupture of intracavernous carotid or delayed hemorrhage due to the carotico-cavernous fistula and/or pseudoaneurysm. There is also evidence that cavernous carotid aneurysms may occur with pituitary tumors, yet largest series failed to demonstrate any link between aneurysm formation and pituitary tumors. Usually such an aneurysm rupture results in formation of carotico-cavernous fistula. However, pituitary apoplexy and even epistaxis have been reported. In this paper we present a patient with recurrent pituitary adenoma and cavernous carotid artery aneurysm, which caused significant hemorrhage during the surgery. Although retrospective analysis of MRI disclosed that the patient had the aneurysm before the first surgery, it remained silent until the second operation. Therefore neurosurgeons should be very susceptive to any signal changes on preoperative MR images, especially in recurrent cases, where normal anatomical relations are disturbed by fibrotic tissue. Also, we reviewed the vascular complication of pituitary surgery based on the literature.
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Affiliation(s)
- Mustafa Berker
- Department of Neurosurgery, Hacettepe School of Medicine, Ankara, Turkey.
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23
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Kepron C, Cusimano M, Pollanen MS. Fatal hemorrhage following trans--sphenoidal resection of a pituitary adenoma: a case report and review of the literature. Forensic Sci Med Pathol 2010; 6:282-7. [PMID: 20306333 DOI: 10.1007/s12024-010-9154-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2010] [Indexed: 11/27/2022]
Abstract
A 58-year-old woman with acromegaly developed massive epistaxis 7 days following trans-sphenoidal resection of a growth hormone-secreting pituitary adenoma. At autopsy, it was determined that the source of the hemorrhage was a rupture of the intracavernous segment of the internal carotid artery secondary to a bacterial arteritis. We describe the gross dissection and histologic examination undertaken in this unusual case, discuss the possible etiology of the infection and review the potential complications of this surgical approach with a view to improving forensic examination of these patients.
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Affiliation(s)
- C Kepron
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Medical Sciences Building, Room 6215, 1 King's College Circle, Toronto, ON M5S 1A8, Canada.
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Pituitary macroadenoma co-existent with supraclinoid internal carotid artery cerebral aneurysm: a case report and review of the literature. CASES JOURNAL 2009; 2:6459. [PMID: 19829808 PMCID: PMC2740023 DOI: 10.4076/1757-1626-2-6459] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Accepted: 06/05/2009] [Indexed: 11/23/2022]
Abstract
With improved angiographic techniques and magnetic resonance angiography available today, an increasing number of incidental aneurysms are being detected. Occurrence of an intracranial aneurysm together with a pituitary adenoma presents tremendous risk to the patient, particularly when the aneurysm lies near the operative field. A 61-year-old woman presented with a progressive visual field defect. Neurological examination revealed bi-temporal haemianopia. Cerebral magnetic resonance imaging and angiography revealed a pituitary macroadenoma co-existent with a cerebral aneurysm near the sellar region. The patient underwent an endovascular procedure for aneurysm embolisation and then underwent surgery for removal of the pituitary adenoma via a trans-sphenoidal approach. We report our experience and emphasize the need for critical evaluation of neuroradiological examinations for precise diagnosis for avoiding a possible life-threatening situation.
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