Intra-Operative Rupture of Remote Aneurysm during Transphenoidal Resection of Pituitary Macroadenoma

Gary Rajah,Mark Hornyak

doi:10.4236/ojmn.2014.42014

Abstract

Rupture of intracranial aneurysm resulting in subarachnoid hemorrhage is well known to carry significant risk of poor outcome. Intra-operative rupture of an unknown intracranial aneurysm during a neurosurgical procedure is a rare occurrence that can lead to devastating consequences if not recognized and managed appropriately. Here we describe to our knowledge, the first reported case of previously unknown, remote from the surgical site, intra-operative posterior cerebral artery aneurysm rupture during transnasal endoscopic transphenoidal resection of a pituitary macroadenoma, review relevant literature, and discuss strategies to reduce surgical risk and improve patient outcomes.

Highlights

The relationship between intracranial aneurysms and pituitary adenomas has been well described
It is generally accepted that intracranial aneurysms occur in up to 5% of the general population [3] [4], while pituitary adenomas may be found in up to 16% of the population [5]
A later report suggests the incidence of IA associated with pituitary adenoma is somewhere between 3.7% - 7.4% and 97% of these were in anterior circulation [3]

Summary

Introduction

The relationship between intracranial aneurysms and pituitary adenomas has been well described. A 68-year old woman presented for outpatient neurosurgical consultation with chief complaint of visual loss She reported several months of declining vision. She was referred for MR imaging which revealed a pituitary macroadenoma with suprasellar extension causing compression of the optic chiasm (Figure 1). She underwent elective endoscopic transphenoidal resection of the pituitary tumor. The patient recovered to her baseline mental status in the intensive care unit, but suffered from a left oculomotor nerve palsy She underwent endoscopic removal of nasal packing on postoperative day 6, and she was discharged to inpatient rehabilitation without further complication on post operative day 12 with persistent third cranial nerve palsy. More than 3 years after treatment, she remains without neurological deficit, repeat angiogram is without recurrence of the aneurysm and MRI shows no tumor recurrence (Figure 3); she remains on hydrocortisone and thyroid hormone

Findings

Discussion

Conclusion