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

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.

Simultaneous Aneurysmal Subarachnoid Hemorrhage and Epistaxis in an Untreated Prolactinoma: A Case Report and Literature Review

“…Patients with PA are known to have a higher likelihood of coexisting brain aneurysms, approximately seven times greater than other types of brain tumor patients, with occurrence rates ranging from 0.5% to 7.4%. Mercuri et al reported a review of 150 cases of coexisting brain aneurysms and PA. 10) The nonsecreting type was the most common, accounting for 43% of cases, followed by GH-producing tumors at 34%. The location of the tumors was mainly in the cavernous portion, representing 71% of the cases.…”

“… 12 ) Aneurysms associated with giant prolactinomas are often partially or completely embedded within the tumor, similar to the present case, requiring an optimal treatment strategy tailored to the patient. 10 )…”

“…In the case of giant prolactinomas, some opinions suggest that priority should be given to cabergoline treatment for tumor reduction and normalization of PRL level due to their high invasiveness and the fragility of the aneurysm wall. 10 ) However, three cases of tumor shrinkage and aneurysm rupture following cabergoline treatment have previously been reported, 7 - 9 ) suggesting that we should be aware of the possibility of aneurysm coexistence. In the presence of coexisting aneurysms, aneurysm treatment should be prioritized.…”

“…12) Aneurysms associated with giant prolactinomas are often partially or completely embedded within the tumor, similar to the present case, requiring an optimal treatment strategy tailored to the patient. 10) Medical treatment of asymptomatic prolactinomas has advantages and disadvantages. In the present case, because no symptoms of hyperprolactinemia were noted and the patient experienced simultaneous rhinorrhea and SAH, we intentionally did not attempt to treat the patient with medications due to concerns regarding the risk of CSF rhinorrhea and rebleeding following tumor shrinkage.…”

Glymphatic transport is reduced in rats with spontaneous pituitary tumor

“…Previous investigations demonstrated a higher incidence of intracranial aneurysms in patients harboring pituitary tumor than in the general patient population (82)(83)(84), with the circle of Willis being the most common location for aneurysm (83,85). The increased incidence of aneurysms coexisting with pituitary tumors represents the tumor-induced degenerative modification of vessel wall (85)(86)(87)(88).…”