A Case Report of Pituitary Apoplexy with Concomitant Subarachnoid Hemorrhage

Introduction: Pituitary adenomas and unruptured intracranial aneurysms can occur in up to 7.4% of patients harboring pituitary tumors. Although pituitary apoplexy can be found in as high as 16.6% of patients with pituitary tumors, only 5% manifest acutely with clinical symptoms. Only two prior publications have reported the presentation of both pituitary apoplexy and a ruptured intracranial aneurysm. We add to the available literature a case report of a patient presenting with a ruptured anterior communicating artery aneurysm with symptomatic pituitary apoplexy.

Case Presentation: A 74 year-old female presented with acute onset severe headache. She had slowly progressive vision loss for a year prior to her abrupt onset of headache and acute vision loss. Her initial non-contrast CT head showed a hyperdense lesion in the sellar and suprasellar region, associated with prominent interhemispheric subarachnoid hemorrhage. Given her tortuous vascular anatomy with recent aortic stent, CT angiography was initially performed showing evidence of an aneurysm. A diagnostic cerebral angiogram subsequently confirmed an inferiorly and medially projecting anterior communicating aneurysm with an irregular shape and potential rupture point. An MRI was not an option due to a pacemaker implant. The initial treatment plan involved aneurysmal dome protection via endovascular means followed by an endoscopic trans-sphenoidal approach to treat each individual lesion with the least morbidity. Given the patients highly torturous vascular anatomy with poor vascular access, only a direct carotid puncture would have allowed for endovascular treatment. As a result, the patient underwent open microsurgical aneurysm clipping with complete resection of the pathologically confirmed pituitary adenoma and decompression of the optic chiasm. The patient’s hospital course was significant for developing transient diabetes insipidus, but was ultimately discharged with a GCS of 15. The patient did not regain her vision.

Conclusion: Pituitary apoplexy and aneurysmal subarachnoid hemorrhage are both well-defined pathologies. The concomitant presentation of each provided a unique clinical scenario that required multi-disciplinary treatment and an application of several neurosurgical principles. A literature review confirmed the rarity of this clinical entity.