Endovascular Therapy Using Flow Diversion for Giant Internal Carotid Artery Pseudoaneurysm Arising in the Setting of an Invasive Pituitary Macroadenoma

Abstract

This report illustrates the unusual occurrence of a pseudoaneurysm arising in the setting of a skull base mass and describes the first reported use of endovascular flow diversion therapy in such a setting. A 63-year-old man with occasional headaches during the preceding month presented with the acute onset of severe left retroorbital headache and oculomotor nerve palsy. Computed tomography (CT) and CT angiogram revealed a destructive skull base mass with an associated giant probable pseudoaneurysm of the cavernous segment of the left internal carotid artery. The patient underwent endoscopic transsphenoidal biopsy with a subsequent diagnosis of prolactinoma. Endovascular therapy utilizing two Pipeline™ flow diversion embolization devices was performed with subsequent resolution of the patient's headache and improvement in his cranial nerve deficits/cavernous sinus syndrome.A neurysms coincident with invasive skull base masses are unusual. An association between pituitary neoplasms and intracranial aneurysms has been documented. Th e acute development of a cavernous sinus syndrome with associated cranial nerve defi cits in conjunction with an aneurysm entirely encased within a neoplastic lesion supports the diagnosis of an acutely enlarging pseudoaneurysm, and we describe the fi rst reported use of endovascular fl ow diversion therapy in such a setting. Th is case illustrates a diagnostic pitfall with the potential for grave implications in patient outcome if an associated vascular lesion is not appreciated at the time an intracranial mass is diagnosed. CASE PRESENTATIONA 63-year-old man with minor headaches in the preceding month presented to the emergency department following the acute onset of severe left retroorbital headache, ptosis, mydriasis, ophthalmoplegia, and diplopia. Noncontrast head computed tomography (CT) ( Figure 1a ) revealed a large destructive central skull base mass. Subsequently pre-and postgadolinium brain magnetic resonance imaging (MRI) ( Figure 1b, 1c ) delineated the margins and character of the skull base mass, which was centered in the clivus and extended to encase the left greater than right cavernous segments of the internal carotid arteries (ICAs) with partial destruction of the ( Figure 2 ), which revealed additional dysplastic irregular lobular projections arising from the pseudoaneurysm sac. Th e patient underwent an endoscopic transsphenoidal biopsy of the lesion. Histopathologic fi ndings showed a pituitary adenoma, and subsequent laboratory testing showed serum prolactin levels to be 14191.5 ng/mL (normal range 2.1-17.7), compatible with the diagnosis of a prolactinoma.Th e patient was loaded with aspirin and clopidogrel for 1 day and subsequently underwent endovascular therapy utilizing two overlapping Pipeline TM fl ow diversion embolization devices (Medtronic, Minneapolis, MN) measuring 4.25 × 30 mm and 4.5 × 16 mm ( Figure 3 ), extending to the supraclinoid ICA. Th is resulted in an immediate and marked decrease in contrast fl ow within the pseudoaneurysm sac and contras...

Internal Carotid Artery Pseudoaneurysm After Transsphenoidal Pituitary Tumor Resection: A Case Report

“…The reported incidence of ICAP in skull base surgery ranges from 0.4% to 7.4% [1][2][3][4]. The time of diagnosis of ICAP is usually reported between two days to 10 years postoperatively.…”

“…When considering an internal carotid artery injury there are a variety of potential treatment options including endovascular and surgical [8]. Endovascular management options include permanent occlusion, coil embolization, stenting, flow diverter stent, or pipeline embolization device which have all been reported as safe and effective treatments for ICAP [3,4,9,10]. However, surgical management with arterial ligation or revascularization may be necessary in some cases [1,7].…”

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

“… 3 Among the full-detailed reported cases, the most commonly detected endocrinopathies were hyperprolactinemia (58/96, 60.4%) and GH-secreting tumors (33/96, 34.4%). ICA aneurysms have been correlated to hyperprolactinemia in the so-called vasculogenic hyperprolactinemia, 10 much more than the presence of a true prolactinoma (reported in 17.7% of cases).…”

“…38 Xia X, Ramanathan M, Orr BA, et al Expanded endonasal endoscopic approach for resection of a growth hormone-secreting pituitary macroadenoma coexistent with a cavernous carotid artery aneurysm. J Clin Neurosci 2012;19(10):1437-1441 39 Choi HS, Kim MS, Jung YJ, Kim OL. Incidental superior hypophygeal artery aneurysm embedded within pituitary adenoma.…”