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CASE REPORT
Year : 2007  |  Volume : 55  |  Issue : 4  |  Page : 410-412

Association between pituitary adenomas and intracranial aneurysms: An illustrative case and review of the literature


Department of Neurosurgery, University Hospital and Clinics, Columbia, Missouri, USA

Date of Acceptance18-Jan-2007

Correspondence Address:
Ketan R Bulsara
Yale University School of Medicine, Department of Neurosurgery 333 Cedar Street, TMP 4 New Haven, CT 06520
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.33307

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 » Abstract 

The co-existence of cerebral aneurysms and pituitary adenomas is rare. Here, we report a patient with a coexisting anterior communicating artery aneurysm and a pituitary adenoma and review the available literature concerning this phenomenon. There is a debate in the literature regarding any causal relationship between aneurysms and pituitary tumors, although there are many reports of aneurysms caused by trauma or radiation following treatment of pituitary tumors. These simultaneous lesions are best diagnosed with magnetic resonance imaging with magnetic resonance angiography. Craniotomy for simultaneous aneurysm clipping and resection of the pituitary tumor is the best treatment option.


Keywords: Cerebral aneurysm, pituitary tumor, subarachnoid hemorrhage


How to cite this article:
Bulsara KR, Karavadia SS, Powers CJ, Paullus WC. Association between pituitary adenomas and intracranial aneurysms: An illustrative case and review of the literature. Neurol India 2007;55:410-2

How to cite this URL:
Bulsara KR, Karavadia SS, Powers CJ, Paullus WC. Association between pituitary adenomas and intracranial aneurysms: An illustrative case and review of the literature. Neurol India [serial online] 2007 [cited 2018 Jun 17];55:410-2. Available from: http://www.neurologyindia.com/text.asp?2007/55/4/410/33307


The earliest case reports of the coexistence of anterior circulation aneurysms and pituitary adenomas date back to 1959. [1] Based on the various series reported in the literature, the incidence is approximately 3.6%. The coexistence of pituitary adenomas with anterior circulation intracranial aneurysms raises the question as to whether a causal relationship exists. When the coexistence is present, it is usually associated with growth hormone secreting tumors or nonsecreting tumors. Here we present a case of a 73-year-old man who presented with a ruptured anterior communicating artery aneurysm. His workup revealed the coexistence of a pituitary macroadenoma. Our management of these two lesions as well as a review of the literature is presented.


 » Case Report Top


A 73-year-old right-handed white male presented with the worst headache of his life, blurred vision and photophobia. Computed tomography (CT) of his head revealed findings suggestive of a suprasellar lesion. The CT angiography confirmed the presence of an anterior communicating artery aneurysm that measured approximately 9 mm. An approximately 1.8cm lesion suggestive of a pituitary macroadenoma was also present [Figure - 1]. The CSF analysis showed the fluid to be xanthochromic. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) revealed a 17 x 21 x 21 mm suprasellar mass and a 9mm saccular aneurysm at the level of the anterior communicating artery [Figure - 2].

Endocrine evaluation revealed no abnormalities. The patient was taken to the operating room where he underwent a cranial orbital osteotomy for clip ligation of the anterior communicating artery aneurysm and resection of the suprasellar mass, which was consistent with a pituitary macroadenoma. Intraoperative angiogram and postoperative CT showed no evidence of aneurysm or tumor [Figure - 3]. The patient was monitored in the ICU where he continued his recovery and improved cognitively and physically. By the time of discharge, he had achieved independence in his activities of daily living. At his three-month follow-up appointment, he continues to do well.


 » Discussion Top


Etiology of aneurysms in the context of pituitary tumors.

Cases of infectious and traumatic aneurysms in the context of pituitary tumors have been reported. Onishi et al. reported an intracranial mycotic aneurysm following a transsphenoidal surgery for a pituitary adenoma. After treatment with four months of antibiotics, repeat angiography showed no aneurysm present. [2] Mielke et al. reported an intracranial fungal aneurysm that became fatal 10 months after transsphenoidal surgery for a growth hormone secreting adenoma. [3]

Wilson and Dempsey reported one of the first traumatic aneurysms during a transsphenoidal surgery in their series of 250 pituitary adenoma surgeries. [4] In 1990, Reddy et al. [5] treated a patient with acromegaly who had epistaxis postoperatively, but angiography didn't show any abnormality. Five weeks later, another angiography revealed an aneurysm in the cavernous ICA that was treated by surgical trapping. Recently, Laidlaw et al. [6] reported a spontaneous rupture of an aneurysm which coexisted with pituitary apoplexy.

There have been many studies that have shown an association between intracranial aneurysms and radiation that was used to treat pituitary adenomas. This presumably occurs due to radiation-induced arterial damage, which leads to loss of arterial muscle with necrosis and fibrosis of the tunica intima and media, thus causing dilation of the arterial walls. Nishi et al. [7] were the first to report a case of multiple intracranial aneurysms associated with radiation therapy for the treatment of pituitary adenoma. Nine years after radiation treatment of 5000cGy, the patient reported visual disturbances and was found to have these multiple aneurysms.

Several studies have also attempted to link the coexistence of pituitary adenoma and intracranial aneurysms to mechanical factors. In their study of 116 cases, Pia et al. [8] reported that microanatomical changes in the cerebral circulation from compression or traction might lead to increase in blood flow and lead to aneurysmal formation. Hori et al. [9] reported a case of growth hormone secreting pituitary adenoma in direct contact with right ICA aneurysm. They suggested that the aneurysm arose as a result of a traction mechanism that the pituitary adenoma had when it reduced its size that led to the enlargement of the aneurysm.

Hormonal and microcirculatory influences have been suspected as a major etiological factor. There have been many studies with growth hormone pituitary adenomas and intracranial aneurysms. Acqui et al. [10] studied 62 cases of pituitary adenomas and intracranial aneurysms and stated that mechanical, microcirculatory and hormonal factors, especially growth hormone, play an important role in the formation of intracranial aneurysms. In their review of the literature, they reported that ~ 50% of the pituitary adenomas associated with intracranial aneurysms were growth hormone secreting. [10]

Diagnosis of pituitary adenoma and intracranial aneurysm was a challenge before the advent of CT or MRI. Several authors have recommended the use of angiography in evaluating suprasellar masses, but Houdart et al. [11] were the first to report that only carotid arteriography was the most certain and systematic way to evaluate suprasellar masses and to differentiate pituitary tumors and aneurysms. In 1988, Hirsch et al. [12] did a comparison of MRI, CT and angiography and reported that MRI was superior to CT in differentiating parasellar aneurysms from pituitary tumors and recommended that it be the initial diagnostic study in patients with parasellar masses. Hermier et al. [13] also suggest that adding MRA in addition to MRI has a diagnostic role and should be used routinely in the preoperative studies of a patient with pituitary adenoma.

Patients with known pituitary tumors and intracranial aneurysms who complain of severe headache present a diagnostic dilemma of pituitary apoplexy versus aneurysm rupture. A thorough workup including CT, MRI and cerebral angiography is warranted. Lumbar puncture for CSF analysis, as was performed in our case, may also be necessary.

Therapeutic approaches for pituitary adenoma and intracranial aneurysms have also made numerous advances. Gonzalez et al. [14] have reviewed three different approaches (frontotemporal, orbitozygomatic and maxillary extension of the orbitozygomatic) and found that the orbitozygomatic had much greater working area than the frontotemporal approach. Recently, Revulta et al. [15] have reported a minimally invasive neurosurgical technique using a supraorbital keyhole approach to treat a left carotid aneurysm and pituitary adenoma.

Intracranial aneurysms and pituitary adenomas have been reported by multiple authors in multiple studies, yet a clear association between them still does not exist. Magnetic resonance imaging and MRA are the best diagnostic approaches to these lesions. The transsphenoidal surgical approach should be avoided in patients with coexisting intracranial aneurysm and pituitary adenoma, as this can lead to the rupture of the aneurysm.

 
 » References Top

1.Offret G, Aron JJ. Acromegalic syndrome and aneurysm of the anterior communicating artery. Bull Soc Ophtalmol Fr 1959;3:228-31.  Back to cited text no. 1  [PUBMED]  
2.Onishi H, Ito H, Kuroda E, Yamamoto S, Kubota T. Intracranial mycotic aneurysm associated with transsphenoidal surgery to the pituitary adenoma. Surg Neurol 1989;31:149-54.  Back to cited text no. 2  [PUBMED]  
3.Mielke B, Weir B, Oldring D, von Westarp C. Fungal aneurysm: Case report and review of the literature. Neurosurgery 1981;9:578-82.  Back to cited text no. 3  [PUBMED]  
4.Wilson CB, Dempsey LC. Transsphenoidal microsurgical removal of 250 pituitary adenomas. J Neurosurg 1978;48:13-22.  Back to cited text no. 4  [PUBMED]  
5.Reddy K, Lesiuk H, West M, Fewer D. False aneurysm of the cavernous carotid artery: A complication of transsphenoidal surgery. Surg Neurol 1990;33:142-5.  Back to cited text no. 5  [PUBMED]  
6.Laidlaw JD, Tress B, Gonzales MF, Wray AC, Ng WH, O'Brien JM. Coexistence of aneurysmal subarachnoid haemorrhage and pituitary apoplexy: Case report and review of the literature. J Clin Neurosci 2003;10:478-82.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Nishi T, Matsukado Y, Kodama T, Hiraki T. Multiple intracranial aneurysms following radiation therapy for pituitary adenoma. Case report. Neurol Med Chir (Tokyo) 1987;27:224-8.  Back to cited text no. 7    
8.Pia HW, Obrador S, Martin JG. Association of brain tumours and arterial intracranial aneurysms. Acta Neurochir (Wien) 1972;27:189-204.  Back to cited text no. 8  [PUBMED]  
9.Hori T, Muraoka K, Hokama Y, Takami M, Saito Y. A growth-hormone--producing pituitary adenoma and an internal carotid artery aneurysm. Surg Neurol 1982;18:108-11.  Back to cited text no. 9  [PUBMED]  
10.Acqui M, Ferrante L, Fraioli B, Cosentino F, Fortuna A, Mastronardi L. Association between intracranial aneurysms and pituitary adenomas. AEtiopathogenetic hypotheses. Neurochirurgia (Stuttg) 1987;30:177-81.  Back to cited text no. 10    
11.Houdart R, Thurel C, Rey A, Chai N. Arteriography in pituitary tumors. Pseudotumoral aneurysm. Neurochirurgie 1975;21:163-8.  Back to cited text no. 11    
12.Hirsch WL, Jr, Hryshko FG, Sekhar LN, Brunberg J, Kanal E, Latchaw RE, et al . Comparison of MR imaging, CT and angiography in the evaluation of the enlarged cavernous sinus. AJR Am J Roentgenol 1988;151:1015-23.  Back to cited text no. 12    
13.Hermier M, Turjman F, Tournut P, Laharotte JC, Sindou M, Froment JC, et al . Intracranial aneurysm associated with pituitary adenoma shown by MR angiography: Case report. Neuroradiology 1994;36:115-6.  Back to cited text no. 13  [PUBMED]  
14.Gonzalez LF, Crawford NR, Horgan MA, Deshmukh P, Zabramski JM, Spetzler RF. Working area and angle of attack in three cranial base approaches: Pterional orbitozygomatic and maxillary extension of the orbitozygomatic approach. Neurosurgery 2002;50:550-7.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Revuelta R, Arriada-Mendicoa N, Ramirez-Alba J, Soto-Hernandez JL. Simultaneous treatment of a pituitary adenoma and an internal carotid artery aneurysm through a supraorbital keyhole approach. Minim Invasive Neurosurg 2002;45:109-11.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]

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