“Beauty Is in the Eye of the Beholder”: A Giant Internal Carotid Bifurcation Aneurysm as a Rare and Dangerous Differential Diagnosis of a Craniopharyngioma

Introduction: Craniopharyngiomas are supra-/parasellar lesions often presenting with general, unspecific symptoms. Similarly, ICA bifurcation giant aneurysms may also produce calcified, heterogeneous, parasellar expansive lesions, posing a relevant differential diagnosis due to their inherently different surgical strategies and risks.

Case Report: We report a 54-year-old female, presenting with progressive disorientation and apathetic behavior. Computed tomography and magnetic resonance reports described a suprasellar heterogenous mass with calcifications associated with an adjacent, laterally located fluid collection suggestive of a craniopharyngioma. During the surgical approach, perfuse and unexplained arterial bleeding ensued, prompting the surgical team to revise a previous contrast-enhanced CT scan. Careful inspection revealed an image suggestive of a vascular pathology, with an area of continuous hyperdensity along the right ICA bifurcation. The sylvian fissure was dissected, and an aneurysmal neck was encountered and successfully clipped.

Conclusion: Giant intracranial aneurysms are rare but essential differential diagnoses to be considered during the workup and surgical approach of parasellar mass lesions. This case illustrates the importance of CT angiography for skull base lesions, even when the size is more suggestive of tumor pathology ([Fig. 1]).

Fig. 1 A and B: Axial section CT Scan showed a midline mass with peripheral calcification (A) and heterogeneous contrast enhance (B). Right Frontal cystic lesion appears with more intensity than CSF in MRI (C). SWI reconstructions with flow voids (D, E) and sagital T1 with heterogeneous gadolinium enhancement on MRI (F). Prior radiology report suggested Craniopharyngioma. CT Angiography evidenced a hyperdense imaging pattern suggesting luminal patency (red arrows) from an ICA bifurcation aneurysm (G, H, I).

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Artikel online veröffentlicht:
15. Februar 2022