Extracapsular Pituitary Macroadenoma Resection and Internal Carotid Artery Aneurysm Clipping via Endoscopic Endonasal Approach: Technical Description

Pituitary macroadenomas and internal carotid artery parasellar aneurysms are relatively common conditions that occur rarely in the same patient. All skull base surgeons should be aware of the potential of this dangerous and challenging coincidence, and have strategies for safe and effective treatment of both conditions.

We present a case of a 53-year-old woman who began noticing a progressively deteriorating peripheral visual field in her left eye for ∼6 to 8 months. Subsequently, she began noticing rapid decline in her right eye vision, prompting assessment at our institution. A longstanding history of recurrent mild headaches was also obtained.

A large sellar and suprasellar mass, consistent with a pituitary macroadenoma, causing displacement of the optic apparatus was found on CT imaging. In addition, concern of an intracranial internal carotid artery (ICA) aneurysm was raised based on subtle MRI findings. A subsequent CT angiogram confirmed the presence of a parasellar left ICA aneurysm.

Due to the rapid progression of the patient’s visual loss in her right eye and 2 to 3 months’ time frame for preoperative anticoagulation therapy prior to endovascular treatment for her aneurysm, prompt surgical intervention was considered. This patient was taken to the operative room and underwent extracapsular dissection of her pituitary macroadenoma to expose the neck of the aneurysm. The aneurysm was clipped via endoscopic endonasal approach at the same sitting.

Pre- and postoperative imaging, as well as intraoperative images and videos are shown to illustrate the diagnostic and therapeutic nuances.