Double jeopardy - pituitary apoplexy complicated by ruptured aneurysm of the internal carotid artery within an adenoma: a case report

Abstract

Background Sudden onset of severe headache is the most common presentation of a ruptured intracranial aneurysm. Similar symptoms can be caused by pituitary apoplexy, and radiological examination is needed to distinguish between the two. Development of infarction and/or haemorrhage of the hypophysis with concomitant unruptured cerebral aneurysm has been described. However, intratumoural aneurysm within a pituitary adenoma presenting with the ictus of both pathologies is extremely rare. Case presentation A 64-year-old man presented with classic symptoms of pituitary apoplexy. His symptoms improved after a few days, and he was discharged. However, he subsequently developed further episodes of sudden and severe headache together with visual decline and ophthalmoplegia. Radiographs demonstrated an enlarging sellar mass with suspicion of a ruptured internal carotid artery aneurysm, within the apoplectic pituitary macroadenoma. Although an endovascular procedure was planned, the patient developed massive subarachnoid haemorrhage resulting in brain death. Conclusion This case report describes an intratumoural aneurysm of the cavernous internal carotid artery as a potential cause or result of pituitary apoplexy. Despite its rarity, this possible life-threatening complication of pituitary apoplexy should be recognised for prompt diagnosis and early management.

An unusual presentation of hypopituitarism caused by a sellar aneurysm

“…One of these cases showed that, at 6 months, complete functional recovery of the pituitary gland postoperatively was not achieved, though functional improvement via hormone loading test was confirmed ( 24 ). Other cases reported complete functional recovery at 3-month ( 18 ) and 10-month ( 23 ) follow-up visits, while one group of authors showed no improvement at 1 month after treatment ( 25 ); no further pituitary function assessments were reported for either of the cases. Another group of authors reported a case of a giant ICA aneurysm with pituitary dysfunction successfully treated with high-flow bypass using radial artery graft followed by ligation of the ICA at the cervical portion; at the 1-year follow-up, the patient presented with normal pituitary hormone levels, and at the 8-year follow-up visit, remained without hormonal replacement therapy, with good patency of the graft confirmed by MRI ( 26 ).…”

“…One of these cases showed that, at 6 months, complete functional recovery of the pituitary gland postoperatively was not achieved, though functional improvement via hormone loading test was confirmed (24). Other cases reported complete functional recovery at 3-month (18) and 10-month (23) follow-up visits, while one group…”

“…Moreover, ICA aneurysms could coexist in direct contact with a pituitary adenoma. These pathologies could also lead to a diverse clinical presentation ( 18 ). Such heterogeneity in clinical presentation, the origin of the intrasellar aneurysm, and potential coexistent pathologies make each case a piece of a larger puzzle that remains to be solved.…”