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

Song RX, Wang DK, Wang Z, Wang ZW, Wang SX, Wei GX, Li XG - J Med Case Rep (2014)

Bottom Line: She had nuchal rigidity and reduced vision.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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Neurosurgery, Qilu Hospital of Shandong University, 107 Wenhua West Street, Jinan 250012, P,R, China. naokesongrenxing@sina.com.

ABSTRACT

Introduction: A 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 presentation: A 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.

Conclusion: Our 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.

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Postoperative magnetic resonance imaging of the brain. Postoperative cranial magnetic resonance imaging revealed satisfactory result.
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Figure 4: Postoperative magnetic resonance imaging of the brain. Postoperative cranial magnetic resonance imaging revealed satisfactory result.

Mentions: A 31-year-old right-handed Han Chinese woman experienced severe headache, vomiting and blurred vision lasting for two days. On her admission to the hospital, a brain CT scan demonstrated a small amount of increased signal in her basal cisterns, but no evidence of intrasellar and suprasellar lesions were seen (Figure 1A, B). The appearance suggested an 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. A cerebral digital subtraction angiography was subsequently performed, which revealed a 6mm left posterior communicating aneurysm (Figure 1C).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 raised suspicion of pituitary tumor (Figure 2B, C). The anterior part of the tumor capsule was opened and a necrotic tumor mixed with dark old blood was removed (Figure 2C). The appearance suggested pituitary apoplexy.Histopathology revealed a pituitary adenoma with evidence of hemorrhagic necrosis (Figure 3).Our patient made a good recovery. Her postoperative vision was fully recovered. Examinations revealed no hormonal or visual disturbances. Postoperative cranial MRI (magnetic resonance imaging) revealed a satisfactory result (Figure 4). She had diabetes insipidus for 10 days postoperatively, which then resolved. She remained asymptomatic and was discharged home on postoperative day 11. She has been followed closely as an outpatient since discharge, and has remained asymptomatic.


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

Song RX, Wang DK, Wang Z, Wang ZW, Wang SX, Wei GX, Li XG - J Med Case Rep (2014)

Postoperative magnetic resonance imaging of the brain. Postoperative cranial magnetic resonance imaging revealed satisfactory result.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4155771&req=5

Figure 4: Postoperative magnetic resonance imaging of the brain. Postoperative cranial magnetic resonance imaging revealed satisfactory result.
Mentions: A 31-year-old right-handed Han Chinese woman experienced severe headache, vomiting and blurred vision lasting for two days. On her admission to the hospital, a brain CT scan demonstrated a small amount of increased signal in her basal cisterns, but no evidence of intrasellar and suprasellar lesions were seen (Figure 1A, B). The appearance suggested an 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. A cerebral digital subtraction angiography was subsequently performed, which revealed a 6mm left posterior communicating aneurysm (Figure 1C).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 raised suspicion of pituitary tumor (Figure 2B, C). The anterior part of the tumor capsule was opened and a necrotic tumor mixed with dark old blood was removed (Figure 2C). The appearance suggested pituitary apoplexy.Histopathology revealed a pituitary adenoma with evidence of hemorrhagic necrosis (Figure 3).Our patient made a good recovery. Her postoperative vision was fully recovered. Examinations revealed no hormonal or visual disturbances. Postoperative cranial MRI (magnetic resonance imaging) revealed a satisfactory result (Figure 4). She had diabetes insipidus for 10 days postoperatively, which then resolved. She remained asymptomatic and was discharged home on postoperative day 11. She has been followed closely as an outpatient since discharge, and has remained asymptomatic.

Bottom Line: She had nuchal rigidity and reduced vision.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.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Neurosurgery, Qilu Hospital of Shandong University, 107 Wenhua West Street, Jinan 250012, P,R, China. naokesongrenxing@sina.com.

ABSTRACT

Introduction: A 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 presentation: A 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.

Conclusion: Our 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.

Show MeSH
Related in: MedlinePlus