Endoscopic Extracapsular Removal of Pituitary Adenoma: The Importance of Pretreatment of an Adjacent Unruptured Internal Carotid Artery Aneurysm

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.

Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report

“…However, in the absence of sufficient data and a scarcity of such reports in the literature, guideline-based management of incidentally discovered aneurysms should be considered. [ 36 ] The currently established guidelines for the management of unruptured intracranial aneurysms reflect the propensity for growing aneurysms to rupture and warrant endovascular treatment of unruptured intracranial aneurysms in this setting. [ 33 ]…”

Preoperative Coiling of Coexisting Intracranial Aneurysm and Subsequent Brain Tumor Surgery

“…Thus, cUIA coiling and subsequent tumor surgery is an alternative option. However, only a few cases treated by this strategy are reported in literature (171819). To our knowledge, this study is the first case series collected over an 11-year period at a single large center, where the safety and efficacy of preoperative coiling and subsequent brain tumor surgery has been evaluated.…”

“…This data emphasizes the importance of cUIA management before tumor treatment (121011121314). However, few studies have investigated treatment strategies for brain tumor with cUIA (1516171819). Preoperative coiling and subsequent tumor surgery is one strategic option for treating cUIA prior to brain tumor surgery.…”

“…Preoperative coiling and subsequent tumor surgery is one strategic option for treating cUIA prior to brain tumor surgery. However, few cases exist in literature, which were treated by this strategy (171819). …”

Pituitary macroadenoma co-existent with a posterior circulation aneurysm leading to subarachnoidal hemorrhage during transsphenoidal surgery

“…Recently, transsphenoidal pseudocapsule-based extracapsular resection has been introduced as a better alternative compared to the traditional intracapsular approach, with emphasis on the detection and pretreatment of an adjacent unruptured intracerebral aneurysm (35).…”