Magnetic resonance imaging finding of coexistence of bilateral paraclinoid aneurysms in a patient with a nonfunctioning macroadenoma, simultaneous resection, and clipping: illustrative case

Abstract

BACKGROUND Unruptured incidental intracranial aneurysm can coexist with pituitary adenoma, however, the occurrence is extremely rare. Timely diagnosis of asymptomatic intracranial aneurysms with pituitary adenoma may lead to planning a tailored surgical strategy to deal with both pathologies simultaneously. A case of a patient who underwent transcranial resection of a pituitary adenoma with clipping of two mirror aneurysms is reported. OBSERVATIONS A 55-year-old female presented with deterioration of visual acuity that progressed over 1 year, as well as presence of right eyelid ptosis. Magnetic resonance imaging of the head showed the presence of an intrasellar pituitary macroadenoma. Bilateral paraclinoid aneurysms were documented to be in contact with the pituitary tumor. The patient underwent surgery with simultaneous aneurysm clipping and tumor resection through a standard pterional approach with intradural clinoidectomy. The aneurysms were successfully clipped after the tumoral debulking. After clipping, the pseudocapsule was fully resected. LESSONS Various treatment options are available. Although endovascular securing of the aneurysms prior to the tumor resection would be ideal, in cases in which this resource is not readily available at all times, the surgeon must be prepared to solve pathologies with an elevated level of complexity.

Surgical treatment of pituitary neuroendocrine tumors with coexisting intracranial lesions: A case series and review of the literature

“…The coexistence of PitNET with other intracranial lesions is unusual, especially when patients with previous irradiation therapy for pituitary tumors have been excluded from the study. However, in the current medical literature, there are several case reports of PitNET associated with other intracranial lesions, such as craniopharyngiomas,[ 15 ] lymphomas,[ 32 ] gliomas,[ 4 ] aneurysms,[ 17 , 19 , 24 - 27 , 33 , 36 ] and meningiomas[ 1 , 5 , 11 , 13 , 22 , 30 , 35 , 41 , 42 ] among others. However, it should be noted that both aneurysms and meningiomas are the most consistently reported ones and even several pathophysiologic theories have been proposed to explain their association.…”

“…The diagnosis of IA associated with PitNET is usually an incidental finding while carrying out preoperative image studies, and most of the IA are silent and unruptured; therefore, the clinical manifestations of the patients are usually due to the mass effect or hormonal secretion of the pituitary tumor. [ 24 , 27 , 36 ] However, there have been reports of fatal epistaxis and pituitary apoplexy secondary to the rupture of these aneurysms. [ 18 , 39 ] Hence, the misdiagnosis of these conditions may lead to the accidental rupture of IA during tumoral resection, leading to lethal hemorrhagic consequences.…”

“…[ 9 ] Nevertheless, MRI angiography and computed tomography angiography (CTA) are less invasive alternatives, especially CTA, which is more accessible, quick, and has higher sensitivity than MRA. [ 17 , 24 , 27 , 39 ] In our institution, we routinely perform preoperative CTA and MRI for patients with PitNET with significant suprasellar and/or parasellar extension for both assessing the perisellar vasculature as well as for neuronavigation.…”

“…Based on the current literature and our institutional experience, it is advisable to treat the IA at the first stage (whether with microsurgical or endovascular procedures) and then proceed with the tumoral resection. [ 9 , 24 , 25 , 36 ] Both treatments may be performed in one or two surgical stages, but always securing the IA before the tumoral resection to avoid potential catastrophic hemorrhages, especially when both lesions are close to each other. [ 9 , 24 , 25 , 33 ] The planning of the surgical strategy must be tailored to the patient, and several factors should be considered for treatment selection, especially the spatial arrangement between the IA and the PitNET.…”

“…[ 17 ] reported a higher prevalence of IA in patients with PitNET (8.3%) in comparison to general control subjects (2.4%), thus suggesting a causal relationship between them and raising doubts about the best therapeutic option in these scenarios. [ 24 - 26 , 33 , 36 ]…”