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.

Keywords: cavernous sinus; cerebral aneurysms; flow diverter; internal carotid artery; pituitary adenoma; prolactinoma.

Fig. 1

The flow-chart of article selection.

Fig. 2

( A ) Head CT scan three-dimensional volume reconstruction showing the cICA pseudoaneurysm, the petrous internal carotid artery (pICA), the basilar artery (BA), and anterior cerebral artery (ACA). Note the fetal origin of the left PComA (#) and hypoplastic left A1 segment (*) and the extensive erosion of the middle cranial fossa caused by the giant prolactinoma ( white arrows ); ( B–D ) gadolinium enhanced brain MRI T1-weighted sequences in the three planes showing a voluminous neoformation packing the sphenoid sinus ( white arrows ) with an extension into the cavernous sinus, infiltration of the mesial temporal dura, middle cranial fossa, and initial involvement of the infratemporal fossa presenting an inner portion with flow signal in continuity with the ICA. ( E–F ) Digital subtraction angiography demonstrating a large pseudoaneurysm of the cICA.

Fig. 3

Contrast-enhanced MRI performed 1 year after treatment documents extensive reduction of the mass with disappearance of compression on nerve structures. The aneurysm isolated from the circulation is maintained under observation at follow-up.