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. 2022 Mar 7;3(10):CASE21699.
doi: 10.3171/CASE21699. Print 2022 Mar 7.

Staged endovascular treatment of a coexisting parasellar aneurysm and endoscopic resection of a pituitary macroadenoma: illustrative case

Aishwarya Nene  1 , Christopher S Hong  2 , Declan McGuone  3 , Charles C Matouk  2 , S Bulent Omay  2
Affiliations

Staged endovascular treatment of a coexisting parasellar aneurysm and endoscopic resection of a pituitary macroadenoma: illustrative case

Aishwarya Nene et al. J Neurosurg Case Lessons. .

Abstract

Background: Intracranial aneurysms and pituitary adenomas are relatively common pathologies that, in rare instances, may concurrently present. Their management poses considerable clinical and technical challenges.

Observations: The authors present a case of a 66-year-old female patient with a fusiform aneurysm of the left internal carotid artery associated with a symptomatic pituitary macroadenoma that had been causing visual deficits for the past several years. She underwent successful placement of flow diverter stents across her aneurysm, followed by routine dual antiplatelet therapy to maintain stent patency. She underwent frequent serial radiographic, endocrine, and ophthalmological evaluations during this time to ensure stability of her pituitary adenoma. Following confirmation of aneurysm obliteration and subsequent de-escalation of antiplatelet medications to aspirin monotherapy, her tumor was subsequently resected via an endoscopic endonasal approach in a delayed fashion.

Lessons: The authors review the literature regarding management of these concurrent pathologies and describe the aspects of the case that led them to their chosen treatment strategy. An algorithm is proposed regarding the management of parasellar aneurysms with a concurrent diagnosis of pituitary tumor pathology.

Keywords: endonasal endoscopic approach; fusiform aneurysm; intracranial aneurysm; parasellar; pituitary adenoma.

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Conflict of interest statement

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Figures

FIG. 1.
FIG. 1.
Preoperative imaging. A large, 3.8-cm enhancing sellar lesion is seen on sagittal (A) and coronal (B) T1-weighted postcontrast MRI, consistent with a pituitary macroadenoma. A 7-mm medially directed left parasellar ICA aneurysm is shown on a coronal image (C) from a bone-windowed CTA and a three-dimensional reconstruction (D) centered on the sella. Repeat imaging obtained 7 months after pituitary adenoma surgery shows no evidence of tumor recurrence on sagittal (E) and coronal (F) T1-weighted postcontrast MRI.
FIG. 2.
FIG. 2.
Digital subtraction angiography. Anterior–posterior (A) and lateral (B) views of a left ICA injection show a medially directed parasellar fusiform aneurysm. C: A lateral oblique view is shown after stent deployment (inset) across the aneurysm. Postoperative anterior–posterior (D) and lateral (E) views of a selective left ICA injection obtained 6 months after stenting shows near obliteration of the aneurysm with a patent stent construct (insets). F: A coronal view of a bone-windowed CTA obtained 1 year after stenting shows complete obliteration of the aneurysm.
FIG. 3.
FIG. 3.
Histopathology of the pituitary adenoma. A representative hematoxylin and eosin stain (A) is shown with effacement of reticulin (B). The tumor exhibits diffuse neuronal positivity for transcription factor SF1 (C) and contains rare follicle-stimulating hormone–positive cells shown with black arrows (D). In all images, original magnification is 200×.
FIG. 4.
FIG. 4.
A proposed framework for treatment of patients with pituitary tumors with coexisting parasellar aneurysms. EC-IC = extracranial–intracranial.
See this image and copyright information in PMC

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