Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report
- Georgia Neurosurgical Institute, Macon, Georgia, USA
- Department of Neurosurgery, Yerevan State Medical University, Yerevan, Armenia
- Glendale Adventist Comprehensive Stroke Center, Los Angeles, California, USA
Georgia Neurosurgical Institute, Macon, Georgia, USA
DOI:10.4103/sni.sni_317_17Copyright: © 2018 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Tigran Khachatryan, Marina Khachatryan, Ruben Fanarjyan, Mikayel Grigoryan, Arthur Grigorian. Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report. 14-Feb-2018;9:30
How to cite this URL: Tigran Khachatryan, Marina Khachatryan, Ruben Fanarjyan, Mikayel Grigoryan, Arthur Grigorian. Enlargement of an incidental internal carotid artery aneurysm embedded in pituitary adenoma associated with medical shrinkage of the tumor: Case report. 14-Feb-2018;9:30. Available from: http://surgicalneurologyint.com/surgicalint-articles/enlargement-of-an-incidental-internal-carotid-artery-aneurysm-embedded-in-pituitary-adenoma-associated-with-medical-shrinkage-of-the-tumor-case-report/
Background:Currently, transsphenoidal surgery (TSS) is the preferred method for surgical treatment of intrasellar pituitary adenomas. However, it carries some risk of intraoperative arterial injuries, which is mainly attributed to direct iatrogenic rupture of the internal carotid artery (ICA). There is anecdotal evidence suggesting that intracranial aneurysms are coincidentally found significantly more frequently in the setting of pituitary adenomas than when the incidence is compared to other intracranial neoplasms. The exact cause of this discrepancy remains unclear, but it certainly raises concerns about the potential existence of an ICA aneurysm, which might be encountered during TSS and in some cases may cause hemorrhagic complications.
Case Description:We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm which was embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor was associated with enlargement of the observed aneurysm, warranting endovascular intervention.
Conclusions:This case report is an illustration for physicians to be conscientious about the potential danger posed by the coexistence of an intratumoral aneurysm in the setting of a pituitary adenoma. Special attention should be given to recognition of an intrinsic flow void signal on the presurgical imaging of the tumor, and if observed, magnetic resonance angiography (MRA) should be performed for preoperative planning. If MRA is not performed routinely, detailed review of high-resolution magnetic resonance imaging is recommended to detect any flow artifacts suggestive of an aneurysm.
Keywords: Aneurysm, coincidence, complications, iatrogenic injury, intraoperative bleeding, pituitary adenoma, transsphenoidal
Currently, microscopic or endoscopic transsphenoidal surgery (TSS) is the preferred method for the treatment of intrasellar pituitary adenomas.[
We present a case of a patient who was found to have a growth hormone (GH)-secreting pituitary adenoma and a coexisting cavernous ICA aneurysm embedded within the tumor. The patient underwent medical treatment of the adenoma. However, shrinkage of the tumor resulted in simultaneous enlargement of the observed aneurysm warranting endovascular intervention.
A 37-year-old female presented to our department after noticing progressive enlargement of her jaw, ears, nose, and fingers. Physical examination and comparison to previous photographs confirmed acromegaly. Further neurological examination including formal visual field testing was within normal limits. A full spectrum of pituitary axis investigations was performed, which revealed increased levels of IGF-1 (1109 ng/ml) as well as increased levels of GH (15 ng/ml). All other hormonal laboratory results were within the normal reference range.
High-resolution magnetic resonance imaging (MRI) of the brain with contrast media was performed, which revealed a 17.5 mm × 15.7 mm × 17.4 mm pituitary macroadenoma with stalk displacement. The patient was admitted to our department for elective transsphenoidal surgery. During the preoperative review of MRI films, a subtle area of flow void was noticed within the right anterior aspect of the tumor [
The decision was made to perform a magnetic resonance angiography (MRA) for a more detailed visualization of the vasculature, which revealed a 2.5-mm cavernous ICA aneurysm pointing towards the sella.
A detailed discussion was then carried out with the patient about the natural history of adenomas and all available treatment options, including endovascular treatment of the aneurysm followed by TSS. We also discussed associated risks and benefits as well as the risks of leaving the adenoma untreated. The patient elected to first pursue medical treatment for pituitary adenoma with close follow-up for the aneurysm.
Shortly after initiation of monthly intramuscular injections of 30 mg of octreotide depot and twice a week administration of 0.25 mg oral cabergoline, the patient noticed a significant decrease in the soft tissue swelling of her face and extremities. IGF-1 levels showed a steady decline from 1109 ng/ml to 353.1 ng/ml over the follow-up period of 1.5 years. The efficacy of medical therapy was also confirmed by a steady decline in tumor size from 17.5 mm × 15.7 mm × 17.4 mm to 10.9 mm × 4.9 mm × 8.9 mm [Figure
Six months later a CT angiography was performed at an outside hospital where the patient was seen for a second opinion [
Given the steady increase in the size of the aneurysm and considering the absence of reliable data about the natural history of intratumoral aneurysms, the patient was again offered endovascular treatment and subsequently underwent a successful stent-assisted coil embolization of the aneurysm without complications [
Rupture of aneurysms located in the parasellar cavernous segment of the ICA occurs rarely. It is usually clinically silent though cranial nerve deficits have been reported in some cases.[
TSS is the preferred method of treatment for GH-secreting tumors, and medical therapy is indicated in cases when contraindications to surgery exist.[
There are several case reports about the development of a postoperative pseudoaneurysm of the ICA.[
According to Choi et al., incidental intracranial aneurysms are found seven times more frequently in pituitary adenomas than in other types of tumors.[
Finally, there is no reliable data about the natural history of coexisting aneurysms in the presence of GH-secreting pituitary adenomas. Spitler et al. have found a higher incidence in aneurysm growth rate in patients suffering from GH-secreting tumors.[
Single case reports do not provide enough evidence to draw scientific conclusions. However, they can serve as a reminder about potential perils in daily practice.
Eye-catching pathologies often draw attention away from other subtle coincidental findings. Neurosurgeons must remain alert about possible coincidental pathologies, which may lead to devastating intraoperative complications. Special attention should be devoted to recognition of a flow void within the tumor and MRA should preferably be performed during the preoperative planning. If MRA is not performed, detailed review of high-resolution MRI should be conducted to reveal any flow artifacts suggestive of an aneurysm. The association of tumor shrinkage and aneurysm enlargement in our case does not imply causality. A prospective multicenter screening study could reveal the true incidence of intrasellar aneurysms associated with pituitary adenomas and compare its natural history to that of other types of intracranial aneurysms.
Eye-catching pathologies often draw attention away from other subtle coincidental findings. Neurosurgeons must remain alert about possible coincidental pathologies, which may lead to devastating intraoperative complications.
Special attention should be devoted to recognition of a flow void within the tumor and MRA should preferably be performed during the preoperative planning. If MRA is not performed, detailed review of high-resolution MRI should be conducted to reveal any flow artifacts suggestive of an aneurysm.
The association of tumor shrinkage and aneurysm enlargement in our case does not imply causality. A prospective multicenter screening study could reveal the true incidence of intrasellar aneurysms associated with pituitary adenomas and compare its natural history to that of other types of intracranial aneurysms.
The patient has consented to submission of this case report to the journal.
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Conflicts of interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
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