gms | German Medical Science

We report the rare case of pituitary apoplexia associated with a simultaneously ruptured AcoA aneurysm. Such an acute coincident pathology has not been reported until now.

A 71-year-old women with one-year history of prolonged visual deficits presented with abrupt onset of headache, nausea, vomiting, complete loss of vision and ophthalmoplegia. There were no previous clinical signs of endocrine disturbance. Initial CT-scan showed a large contrast enhancing intra- and suprasellar mass including hemorrhages. The diagnosis of pituitary apoplexia was obvious. In addition a subarachnoid hemorrhage located in the frontal interhemispheric fissure and a small parenchymal hematoma in the right gyrus rectus was found. 3D reconstructed Computed tomography angiography showed a suspicious bulge at the AcoA junction but no definite cerebral aneurysm.

Due to the acute onset of complete amaurosis we performed an emergency transcranial operation via a pterional approach without further investigations. After decompression of the suprasellar tumor, a saccular aneurysm of the AcoA fixed to the tumor was exposed. There was obviously a concomitatnt SAH. The aneurysm was clipped and the tumor was completely removed releasing the chiasm and optic nerve. Postoperatively the patient presented a transient diencephalic syndrome but her clinical course improved with slight neuropsychological deficits. Ophthalmoplegia receded but the visual deficits persisted.

We assume that the rupture of the aneurysm was caused by the acutely increased tension of the tumor capsule originated by the bleeding of the pituitary adenoma. Since the association of an acute hemorrhage into a giant pituitary adenoma associated with the rupture of an AcoA aneurysm is a very rare event, there are no standard recommendations for the diagnostic and therapeutic management. When SAH is present in pituitary apoplexia, one should consider this combination and be prepared for it.