Epistaxis and pituitary apoplexy due to ruptured internal carotid artery aneurysm embedded within pituitary adenoma

Abstract

Epistaxis due to ruptured internal carotid artery (ICA) aneurysm embedded within a pituitary adenoma (PA) has seldom been reported in the literature. Here we want to elaborate the incidence, mechanisms, clinical manifestations, and treatment strategy for this condition. The first survived case of a patient with epistaxis and pituitary apoplexy due to ruptured aneurysm embedded within PA was reported and the literature was reviewed. A 53-year-old male patient presented to our institution with sudden onset epistaxis and progressive vision loss. Neurological examination revealed bilateral ptosis and dilated unresponsive pupils. A CT scan showed a large mass in the pituitary fossa with bony erosion. MRI revealed a large pituitary tumor and abnormal signal intensity in the tumor. No aneurysm was noted during the pre-operative MR angiography. Abundant arterial bleeding suddenly occurred during urgent transsphenoidal surgery. Digital subtraction angiography confirmed the presence of a 14 mm unexpected saccular aneurysm of right ICA in the cavernous sinus with the dome protruding into the sella turcica. Balloon test occlusion of the right ICA was undertaken and permanent occlusion was performed. The patient recovered well and received bromocriptine and thyroid hormone replacement therapy during the follow-up period. At 14-month followup, the patient had no neurological deficits, no features of ischaemia relating to the right ICA therapeutic occlusion. Our case indicated that epistaxis and pituitary apoplexy could be due to the rupture of an ICA aneurysm embedded in a PA. Clinical suspicion should remain high when evaluating any case of epistaxis and pituitary apoplexy. Optimal treatment should take into consideration individual features of the tumor, aneurysm, and patient. Making the correct diagnosis as well as identifying an appropriate management strategy is critical in the care of such patients.

Keywords: Cerebral aneurysm; epistaxis; pituitary adenoma; pituitary apoplexy.

Figure 1

Pre-operative cranial CT disclosed (A) a large soft-tissue mass that arose from the sella and occupied all of the sphenoid sinus, together with (B) bony destruction of the sella turcica, clivus and adjacent petrous temporal bones.

Figure 2

MRI of the brain revealed a large pituitary tumor that extended superiorly in the suprasellar cistern to elevate the optic chiasm and extended inferiorly to fill the sphenoid sinus. (A, B) The mass was isointense to brain parenchyma on T1-weighted MRI, (C) relatively hypointense on T2-weighted MRI. (D-F) Showed significant contrast enhancement after injection of gadolinium. There was abnormal signal intensity consistent with acute hemorrhage in the tumor (black arrow).

Figure 3

No aneurysm was found in bilateral ICA and vertebral artery in the pre-operative MRA.

Figure 4

DSA confirmed the presence of an 14 mm diameter unexpected saccular aneurysm of right ICA in the cavernous sinus with the dome protruding into the sella turcica. Anteroposterior view (A, B), lateral view (C, D) Balloon test occlusion of the right ICA was undertaken under local anesthesia for thirty minutes (E), permanent occlusion was performed using two detachable 8 mm*20 mm Gold Valve balloons (Nycomed, Ingenor, France) deployed in the petrous RICA and distal cervical RICA (F).

Figure 5

Six month postoperative MRI and MRA demonstrated complete obliteration of the aneurysm (A). There were no features of ischemia relating to the therapeutic right ICA occlusion (B). Only 1.3 cm of the intrasellar remnant adenoma, and no signs of optic nerve compression (C, D).