Dangerous liasons: Pituitary adenoma and aneurysm associations: A case report

Introduction: The earliest mention of the coexistence of anterior circulation aneurysms and pituitary adenomas dates back to 1959. The coexistence of pituitary adenomas with anterior circulation intracranial aneurysms raises the question as to whether a causal relationship exists. Case Summary: A 49-year-old woman presented to our institution with a progressive visual field defect, occasional diplopia and oligomenorrhoea. Neurological examination revealed bi-temporal hemianopia (Left > Right). Hormonal studies showed a slight elevation in prolactin levels. MRI showed well defined solid cystic lesion invading seller and supraseller region with displacement of B/L optic nerve. CT scan showed a slightly hyperdense lesion in the sellar region and a partially eroded sellar floor. The patient underwent a radical surgical decompression of the sella and excision of the tumour (prolactin-secreting adenoma) via a transnasal trans-sphenoidal endoscopic approach. Intraoperative controlled normo-tension (Target MAP of 60 mmHg) was maintained with SNP and Esmolol. Patient was extubated (GCS 15/15) and shifted to the ICU. Post operatively she experienced severe headache with vomiting. She underwent MRA and was found to have a ruptured ACOM aneurysm. Supratentorial intracranial aneurysm clipping was performed. Specific attentionwas given to prevent major hemodynamic changes during the entire surgery. Intraoperatively heart rate, transmural pressure gradient, central venous pressure, SPO2, endtidalcarbondioxide, temperature, urine output, blood sugar, arterial blood gas and electrolytes were monitored. The patient was extubated successfully (GCS 15/15) without emergent hemodynamic changes. Postoperatively, we continued SNP infusion to maintain normo-tension. Conclusion: The key to the success in managing these dual lesions is modulating the hemodynamic targets for the individual conditions. Excision of the pituitary adenoma perioperatively demands controlled normotension. However, the cererbral aneurysm clipping requires strict control of the TMP gradient intraoperatively till the clipping of the aneurysm followed by controlled hypertension post clipping.

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