Coexistence of aneurysmal subarachnoid hemorrhage and surgically identified pituitary apoplexy: a case report and review of the literature

Abstract

IntroductionA ruptured aneurysm associated with a pituitary apoplexy is rare. We present the first case report of the coexistence of a ruptured posterior communicating aneurysm with a surgically discovered pituitary apoplexy where the pituitary apoplexy had not been diagnosed by a pre-operative computerized tomography scan.Case presentationA 31-year-old right-handed Chinese woman began to experience severe headache, vomiting and blurred vision which continued for two days. On admission to the hospital, a brain computerized tomography scan demonstrated a small amount of increased signal in the basal cisterns; no evidence of intrasellar and suprasellar lesions was seen. The appearance of her brain suggested aneurysmal subarachnoid hemorrhage. She had nuchal rigidity and reduced vision. There was no extra-ocular palsy and no other neurological deficit. Our patient had no stigmata of Cushing’s syndrome or acromegaly. During an interview for further history, she reported normal menses and denied reduced vision.Cerebral digital subtraction angiography was subsequently performed, which revealed a 6mm left posterior communicating aneurysm. Urgent left pterional craniotomy was performed. The left ruptured posterior communicating artery aneurysm was completely dissected prior to clipping. At surgery, a suprasellar mass was discovered, the tumor bulging the diaphragma sella and projecting anteriorly under the chiasm raising suspicion of a pituitary tumor. The anterior part of the tumor capsule was opened and a necrotic tumor mixed with dark old blood was removed. The appearance suggested pituitary apoplexy.Histopathology revealed pituitary adenoma with evidence of hemorrhagic necrosis. Our patient made a good recovery.ConclusionOur case report proves that pituitary apoplexy can be coexistent with the rupture of a posterior communicating aneurysm. This association should be considered when evaluating any case of aneurysm. A normal computerized tomography scan does not exclude pituitary apoplexy. Pre-operative magnetic resonance imaging interpretation is required if a pituitary apoplexy is suspected. Craniotomy allows a coexisting aneurysm and pituitary apoplexy to be simultaneously treated.

Multidisciplinary Management of Pituitary Apoplexy

“…The rare association between a ruptured aneurysm with SAH and pituitary apoplexy [83] as well as the rupture of an aneurysm embedded within a pituitary adenoma with a clinical evidence of epistaxis has also been reported [84]. Suzuki et al reported a case of pituitary apoplexy caused by an unsuspected aneurysm bleeding into a pituitary adenoma and in which catastrophic intraoperative haemorrhage occurred [85].…”

A case of pituitary apoplexy masquerading as subarachnoid hemorrhage

“…Although our case reveals pituitary apoplexy as the cause of xanthochromia, others have reported the association of apoplexy in conjunction with SAH [3][4][5][6]. Interestingly, there is some association between intracranial aneurysms and pituitary adenomas [7].…”

Subarachnoid Hemorrhage From Rupture of an Undiagnosed Posterior Circulation Aneurysm During Sellar Tumor Surgery

“…In all three cases, postoperative imaging documented a small posterior circulation aneurysm (top basilar, basilar artery-superior cerebellar artery segment, and P1 segment). Preoperative workup never disclosed clearly the presence of the aneurysm, and in contrast with reported cases regarding intraoperative rupture of anterior circulation aneurysms, all three patients had a fatal outcome [5,6,15,16]. Hemodynamic changes are less likely to occur in the posterior circulation while removing a pituitary adenoma or a craniopharyngioma compared with the anterior circulation.…”