Giant, thrombosed, sellar–suprasellar internal carotid artery aneurysm with persistent, primitive trigeminal artery causing hypopituitarism

Abstract

A rare case of a giant, thrombosed, sellar-suprasellar paraclinoid internal carotid artery (ICA) aneurysm with persistent primitive trigeminal artery (PPTA) causing hypopituitarism that manifested as hypogonadism, hypothyroidism, and hypocortisolism is reported. There were no visual/neurological deficits, diabetes insipidus, or episodes of subarachnoid hemorrhage. The alteration in the flow dynamics of the circle of Willis due to the presence of PPTA may have been responsible for both the genesis of the giant aneurysm as well as for the induction of thrombogenesis within its lumen. As the digital subtraction angiogram showed complete thrombosis within the aneurysm and hormonal replacement therapy was effective in ensuring complete normalization of symptoms, the patient was unwilling to undergo surgical clipping of the aneurysm and removal of the suprasellar clot in an attempt to restore pituitary functions. Hypopituitarism recurred when the patient stopped her hormonal supplementation therapy after 7 years, and she again became symptom-free on restarting the therapy. To the best of the authors' knowledge, this represents the first reported case in the literature of hypopituitarism consequent to a giant, thrombosed, sellar-suprasellar ICA aneurysm with an associated PPTA on the side of the aneurysm.

Recovery of pituitary function following treatment of an unruptured giant cavernous carotid aneurysm using Surpass flow-diverting stents

“…8 The mechanisms of the endocrine dysfunction may be due to either direct mechanical compression of the pituitary gland, or vascular compression of the superior hypophyseal artery subsequently causing pituitary ischemia. 9 Other symptoms due to mass effect such as headaches and visual deficit frequently accompany endocrine disturbances in these patients. 9 Hypopituitarism, if present, is usually permanent in most of the cases even after treatment of the giant paraclinoid/cavernous aneurysms.…”

“…9 Other symptoms due to mass effect such as headaches and visual deficit frequently accompany endocrine disturbances in these patients. 9 Hypopituitarism, if present, is usually permanent in most of the cases even after treatment of the giant paraclinoid/cavernous aneurysms. 3 8 There are only a few reports documenting recovery of endocrine function after surgical clipping of the giant ICA aneurysm and decompression of the pituitary gland.…”

Recovery of pituitary function following treatment of an unruptured giant cavernous carotid aneurysm using Surpass flow-diverting stents

“…The most common pituitary dysfunction associated with giant ICA aneurysms in the cavernous region is hypogonadism, followed by adrenal insufficiency and hypothyroidism 8. The mechanisms of the endocrine dysfunction may be due to either direct mechanical compression of the pituitary gland, or vascular compression of the superior hypophyseal artery subsequently causing pituitary ischemia 9. Other symptoms due to mass effect such as headaches and visual deficit frequently accompany endocrine disturbances in these patients 9.…”

“…The mechanisms of the endocrine dysfunction may be due to either direct mechanical compression of the pituitary gland, or vascular compression of the superior hypophyseal artery subsequently causing pituitary ischemia 9. Other symptoms due to mass effect such as headaches and visual deficit frequently accompany endocrine disturbances in these patients 9. Hypopituitarism, if present, is usually permanent in most of the cases even after treatment of the giant paraclinoid/cavernous aneurysms 3 8.…”

Anatomical features and clinical relevance of a persistent trigeminal artery

“…After branching from the posteromedial aspect of the intracavernous ICA, the medial type PTA closely surrounds the pituitary gland and could exert compression on its stalk resulting in hormonal disturbances that may produce hyperprolactinemia due to stalk effect, to complete hypopituitarism. [1554] Moreover, during the planning of surgical approaches to the skull base, it is important to evaluate the vascular anatomy of the sellar and parasellar regions, searching for PTA. The unnoticed presence of a PTA may result in disastrous outcomes following approaches to the sellar or parasellar regions, the cavernous sinus or Gasserian ganglion.…”