A case of TSH-secreting pituitary adenoma associated with an unruptured aneurysm: successful treatment by two-stage operation and gamma-knife]

We report a successfully treated case of invasive TSH-secreting pituitary adenoma associated with an unruptured internal carotid artery aneurysm by two-stage operation and gamma-knife radiosurgery. A 64-year-old woman was admitted to our department with a 3-year history of general fatigue and 1-year history of anxiety, palpitation and hyperhydrosis. Endocrinological examination revealed hyperthyroidism with elevated TSH, GH and somatomedin C. Magnetic resonance images demonstrated a tumor in the sella turcica which extended into the left cavernous sinus, furthermore, indicated aneurysm-like flow void at the ventral part of the left internal carotid artery. The aneurysm was confirmed by conventional angiography. Neck clipping of the aneurysm was performed through pterional approach as the first operation. One month later, at the second operation, the pituitary adenoma except for cavernous sinus portion was resected via the transsphenoidal approach. Immunohistological examination revealed positive for TSH and GH. Gamma-knife radiosurgery with a central dose of 33.3 Gy and peripheral dose of 17 Gy was carried out for residual tumor at the cavernous sinus under both MRI and CT guidance. Posttreatment course was uneventful with normalization of thyroid function at 16 months after gamma-knife. Two-stage operation and gamma-knife radiosurgery is effective for TSH-secreting adenoma extending into the cavernous sinus associated with an unruptured aneurysm.     

侵袭性垂体腺瘤侵袭性的综合判断及其与临床预后的关系

目的分析经侵袭性垂体腺瘤侵袭性的判断标准及其与临床预后的关系。方法回顾性分析我科自2000年1月至2003年5月行经蝶手术切除的具有完整影像学、病理学和随访资料的侵袭性垂体腺瘤82例,随访时间5～30个月。结果侵袭性垂体腺瘤MR影像学特点为鞍底受侵下陷,部分肿瘤突入蝶窦;颈内动脉包绕;海绵窦受累,鞍隔突破等。病理检查以鞍底硬膜浸润的发生率最高。PRL腺瘤的全切率明显低于无功能腺瘤(P<0.01),无功能腺瘤、GH腺瘤与ACTH腺瘤之间相差不明显。PRL腺瘤的复发率较无功能腺瘤和GH腺瘤高(P<0.05)。结论垂体腺瘤的侵袭性生物学行为导致手术全切几率下降,是术后复发的主要原因。     

Internal carotid artery aneurysm in the sella turcica area simulating pituitary tumor

A giant aneurysm of the internal artery is described which was situated in the sella and simulated hormonally inactive hypophyseal adenoma. Axial computer tomography demonstrated a hypophyseal tumour. During operation from intranasal approach through sphenoid sinus massive haemorrhage developed but was controlled with fibrin sponge. Postoperative angiography demonstrated a giant aneurysm of the internal artery situated in the sella. Although this location of aneurysm is exceptionally rare, each case of inactive hormonally pituitary adenoma should be subjected before the operation to cerebral angiography.     

海绵窦间隙在侵袭海绵窦垂体腺瘤神经内镜经鼻蝶入路切除术中的应用

目的 探讨海绵窦间隙在侵袭海绵窦垂体腺瘤神经内镜经鼻蝶入路切除术中的应用价值。方法 回顾性分析2017年1月至2020年10月经鼻蝶入路神经内镜手术治疗的15例侵袭海绵窦垂体腺瘤的临床资料。基于颈内动脉的自然走形,把海绵窦分为上、下、后、外侧间隙,术中对不同间隙内肿瘤采用不同切除方法。结果 肿瘤全切除11例,次全切除4例。术后发生脑脊液鼻漏1例,尿崩6例,垂体功能减退危象1例,眼球外展障碍1例,动眼神经麻痹1例。15例术后随访3~36个月;11例肿瘤全切除中,10例无复发,1例无功能垂体腺瘤复发并动态观察;4例次全切除中,2例无进展;2例术后6个月内行伽玛刀治疗。结论 神经内镜下经鼻入路手术切除侵袭海绵窦垂体腺瘤的效果良好,基于颈内动脉的自然走形的海绵窦间隙划分方法为侵袭海绵窦垂体腺瘤的手术治疗提供了新思路。     

Carotid cavernous aneurysm presenting as pituitary apoplexy.

The authors report an interesting case with a ruptured internal carotid artery aneurysm that presented as a sellar haematoma mimicking radiologically a pituitary adenoma, and clinically a pituitary apoplexy. A 53-year-old woman presented with a 2-week history of episodic severe headache and vomiting associated, 3 days prior to admission, with left ophthalmoparesis and transient right hemiparesis. Brain MRI showed a large intra- and suprasellar mass suggestive of a pituitary macroadenoma. Hormonal profiles showed hyperprolactinaemia and subsequent cerebral angiography demonstrated a carotid cavernous aneurysm. The patient underwent surgery via a subfrontal approach to manage both lesions. At operation, the suspected pituitary adenoma was revealed to be a sellar haematoma; the aneurysm was successfully clipped. Postoperatively, the patient developed hypotension and right hemiparesis which, as well as the third nerve paresis, progressively improved to full recovery. At 12 months follow-up the patient is neurologically intact and generally well. The clinical features, the management of such a case and the importance of differential diagnosis in the acute stage are emphasised and discussed along with relevant literature.     

海绵窦造影在颈动脉-海绵窦瘘及其并发症中的诊断和治疗意义

目的 了解颈动脉一海绵窦瘘(carotid-cavernous fistula,CCF)的血流动力学变化和颈内动脉海绵窦段及其周围静脉窦和静脉的病理改变,为制定更为合理的治疗方案提供依据。方法 1990年4月～1999年4月共收治CCF患者124例,28例施行眼上静脉(superior ophthalmic vein,SOV)海绵窦造影,其中A型17例,B型1例,D型10例。结果 海绵窦造影显示,海绵窦接近正常者12例(42.86％),其中海绵窦狭窄3例,网状海绵窦9例。海绵窦扩大者16例(57.14％),包括局限性扩张呈静脉湖状14例,其中海绵窦囊性占位者5例,即囊中囊表现,提示存在外伤性动脉瘤;海绵窦分隔2例。辅助动脉造影检查发现,CCF合并同侧颈动脉闭塞者2例,颈动脉狭窄3例,合并外伤性动脉瘤5例,其中2例发生严重鼻出血。28例均经眼上静脉入路或眼上静脉+动脉入路闭塞CCF及假性动脉瘤,治疗效果良好。结论 眼上静脉-海绵窦造影与颈动脉造影结合,于动脉外闭塞CCF瘘口或闭塞海绵窦瘘,可提高CCF治疗的成功率并保持载瘘动脉的通畅率,有助于CCF合并颈内动脉海绵窦段损伤及外伤性动脉瘤的诊断与治疗。     

头颈部少见类型动-静脉瘘的血管内栓塞治疗

目的探讨头颈部少见类型动-静脉瘘血管内栓塞治疗的方法及临床价值。方法创伤性伴有基底动脉动脉瘤的基底动脉-基底静脉丛瘘、原始三叉动脉动脉瘤破裂臻致三叉动脉-海绵窦瘘、自发性和创伤性颈外动脉-海绵窦瘘、创伤性颈内动脉-海绵窦瘘伴有椎动-静脉瘘及创伤性颈内动脉-海绵间窦瘘各1例，对此6例少见类型动-静脉瘘患分别采用机械解脱弹簧圈、电解脱弹簧圈以及可脱性球囊技术进行血管内栓塞治疗。结果创伤性伴有基底动脉动脉瘤的基底动脉-基底静脉丛瘘和创伤性颈内动脉-海绵窦瘘伴有椎动-静脉瘘患分两次伶塞，而原始三叉动脉动脉瘤破裂致三叉动脉-海绵窦瘘、自发性和刨伤性颈外动脉-海绵窦瘘、刨伤性颈内动脉-海绵间窦瘘患均一次完成栓塞治疗。手术后临床症状和体征完全消失。无并发症发生。结论血管内栓塞是治疗头颈部少见类型动-静脉瘘的最佳方法，其操作简单．安全可靠，疗效好，并发症发生率低。应作为首选。     

A case of fibromuscular dysplasia presenting with Wallenberg syndrome, and developing a giant aneurysm of the internal carotid artery in the cavernous sinus]

A 25-year-old man developed Wallenberg syndrome (WS). At that time his carotid angiography was normal. When he was 28 years old, he suffered from retinal artery embolism in the left eye. At the age of 30 years, he had an acute onset of abducens nerve palsy in his right eye. The carotid angiography showed a giant aneurysm at the cavernous sinus portion in the right internal carotid artery. At his age of 38, the right oculomotor, trochlear and trigeminal nerves were involved. A vertebral angiography revealed a bead-like formation, and a diagnosis of fibromuscular dysplasia (FMD) was made. An intensive angiographic examination revealed many stenotic or dilated lesions in the carotid, vertebral, coronary, renal, and hepatic arteries. A sural nerve biopsy specimen revealed that the sural vein was involved. In Japan only one case of FMD presenting with WS is known. FMD should be under consideration as an underlying disease, when WS occurred in younger patients with few risk factors. In this patient an angiography revealed no abnormality in the cavernous sinus portion of the internal carotid artery, when he suffered from WS. However, eight years later he was proved to have a giant aneurysm in the cavernous sinus portion. In conclusion, we support the hypothesis that aneurysm may originate from angiographically normal arterial wall in FMD.     

海绵窦内侧壁的显微解剖与扩大经蝶窦入路治疗侵袭海绵窦的垂体腺瘤（附103例分析）

目的研究海绵窦内侧壁结构的解剖特点，并探讨采用扩大经蝶窦入路治疗侵袭海绵窦垂体腺瘤的方法。方法在10具成人新鲜尸头上模拟扩大经蝶窦手术入路，观察海绵窦内侧壁结构的解剖特点。根据解剖学研究结果，指导临床采用扩大经蝶窦手术入路治疗侵袭海绵窦的垂体腺瘤103例。结果垂体侧方的海绵窦内侧壁薄弱，仅有一层疏松的纤维组织结构。颈内动脉是扩大经蝶窦入路海绵窦内所见的主要结构，可分为5段，有3个主要分支。颈内动脉海绵窦段主要的分支有脑膜垂体干、海绵窦下动脉和被囊动脉。向内侧走行的脑膜垂体干和被囊动脉是经蝶窦入路中较易损伤的血管。手术显微镜下全切除肿瘤62例（60．2％），次全切除38例（36．9％），大部切除3例（2．9％）；无手术死亡；手术并发症包括短暂性脑脊液鼻漏5例，暂时性脑神经功能损伤4例，垂体功能低下3例，颈内动脉损伤2例，永久性尿崩症1例。术后行放射治疗17例，γ刀治疗15例，药物治疗13例。随访3个月～8年，2例出现肿瘤复发而予以γ刀治疗。无再手术病例。结论扩大经蝶窦入路是切除侵袭海绵窦垂体腺瘤理想的入路；了解颈内动脉海绵窦段及其分支在解剖形态上的变化，对于减少术中出血，确保术中安全，具有重要意义。     

内窥镜经蝶窦垂体腺瘤切除术

目的 探讨应用内窥镜经蝶窦入路切除垂体腺瘤的方法及优缺点。方法 自2000年6月～2001年2月对12例垂体腺瘤患者施行内窥镜辅助经蝶窦腺瘤切除手术。经单侧鼻腔鼻中隔入路,在0°角内窥镜下分离鼻粘膜,暴露蝶窦前壁,以中鼻甲下缘和蝶窦开口为界切开蝶窦前壁,打开鞍底,切开硬膜,在内窥镜下探查肿瘤和正常腺体的分界,在手术显微镜下切除垂体腺瘤。结果 术后所肩异常升高的激素水平明显下降,无一例发生严重并发症。结论 内窥镜辅助经蝶窦垂体腺瘤切除术能提供良好的照明和手术视野,是一种安全、可行的手术方法。     

扩大经蝶窦入路颈内动脉海绵窦段显微镜、内镜下的解剖学研究

目的研究扩大经蝶窦入路颈内动脉海绵窦段的显微镜及内镜下的解剖特点。方法在10具动静脉灌注染料的成人新鲜尸头上模拟扩大经蝶窦手术入路，在显微镜及内镜下观察颈内动脉海绵窦段的走行特点，及颈内动脉海绵窦段与垂体的关系，测量双侧颈内动脉海绵窦段在不同水平的距离。结果颈内动脉海绵窦段分为5段，有3个动脉分支，其在蝶窦外侧壁上形成颈内动脉隆突，与视神经隆突形成视神经-颈动脉凹陷，是内镜手术中确定中线的标志。颈内动脉前曲段的内侧缘距垂体中线的距离为（11．94±1．90）mm（9．02～14．86mm），后曲段的内侧缘距垂体中线的平均距离为（7．96±2．07）mm（5．64～11．58mm）。结论颈内动脉海绵窦段是扩大经蝶窦手术入路中最重要的解剖结构。内镜下扩大经蝶窦手术可清晰显示海绵窦内的颈内动脉及其分支血管和神经等重要的组织结构，是处理由鞍内侵犯海绵窦内侧壁病变的良好手术方式。     

False aneurysm of cavernous carotid artery and carotid cavernous fistula: complications following transsphenoidal surgery

We present two cases of carotid injury during transsphenoidal surgery for pituitary adenoma. While in one of the cases it resulted in the formation of a false aneurysm of cavernous carotid artery, in the other patient, a carotid cavernous fistula (CCF) formed. The false aneurysm was managed by surgical trapping and the patient had an uneventful recovery. The CCF was initially managed with balloon embolization. The balloon got deflated and resulted in a false aneurysm with persistent CCF. This was occluded with Guglielmi Detachable Coils (GDC). The management options are discussed and relevant literature is reviewed. We emphasize the importance of an early cerebral angiography to know the status of the injured carotid artery and formation of false aneurysm / fistula.     

Pituitary macroadenoma causing symptomatic internal carotid artery compression: Surgical treatment through transsphenoidal tumor resection

Pituitary macroadenomas can invade the cavernous sinus and rarely cause occlusion of the internal carotid artery (ICA). Most patients with symptomatic obstruction of the ICA by a pituitary tumor have been reported as a result of apoplexy. The authors review the literature about this condition and report a 48-year-old man who presented with transient ischemic attacks leading to a stroke. Imaging studies demonstrated complete occlusion of the left ICA and critical narrowing of the right ICA at the level of the clinoid processes, most likely due to macroadenoma mass effect. There was no radiologic evidence of apoplexy. Surgical resection of the tumor and ICA decompression via the transsphenoidal route resulted in prevention of further symptoms. Histopathologic analysis confirmed a nonfunctioning pituitary adenoma without evidence of hemorrhage or intratumoral infarction. This patient, to the authors’ knowledge, is the first documented patient with symptomatic carotid compression by a pituitary adenoma without evidence of apoplexy.     

Fatal epistaxis from the fetal posterior communicating artery – a delayed complication of trans-sphenoidal surgery

Vascular complications following trans-sphenoidal surgery can occur due to injury of the cavernous segment of the internal carotid artery, external carotid artery and its branches or an aneurysm rupture. The incidence of vascular complications in trans-sphenoidal surgery is 0.4% to 1.4%. Vascular injury was encountered in a patient with giant pituitary adenoma who underwent staged trans-sphenoidal tumour removal. Following his third surgery, he had delayed fatal epistaxis. An angiogram revealed a fetal type posterior communicating artery with a blow out of the junction of the posterior communicating artery with the posterior cerebral artery. The diagnosis and management of this condition are discussed.     

A case of multiple fusiform aneurysms presenting homonymous hemianopsia (author's transl)

Fusiform Aneurysms are encountered in elderly persons with advanced arteriosclerosis. When they are enlarged to compress the neighboring structures, they may resemble tumors symptomatically. Especially when situated in close relation to the optic nerve or chiasmatic region, pituitary tumor is likely to be suspected. This is a case of 62 year old female with a giant fusiform aneurysm of the right internal carotid artery extending to the middle cerebral artery which caused left homonymous hemianopsia and a large aneurysm in the cavernous portion of the left internal carotid artery with fusiform extension of the distal portion of the carotid artery which presented left blepharoptosis, dilated pupil and total ophthalmoplegia. The basilar artery and the right meningohypophyseal artery showed fusiform dilatation as well. Systemic atherosclerotic change, abdominal aortic aneurysm, nephrosclerosis were also accompanied. The computed tomography demonstrated the aneurysms distinctly. Left oculomotor palsy disappeared after six months with residue of left homonymous hemianopsia. Surgical intervention was not attempted, because of the widely distributed constitutional aneurysms in the whole body.     

Diagnostic approaches to pituitary adenomas

The utility of diagnostic tests for pituitary adenoma was compared in 12 patients. Endocrine and radiologic studies were always abnormal, even when neuro-ophthalmologic tests were normal. In most cases, both tomography of the sella turcica and CT scan revealed a mass in the region of the sella turcica. For more precise definition of suprasellar extension of the mass, metrizamide CT cisternography or tomographic pneumoencephalography with metrizamide provided similar details, although CT cisternography was much more easily done. Angiography provides a means to exclude an aneurysm or vascular malformation, a vascular tumor, or an aberrant course of the internal carotid artery.     

Anatomical location of carotid cave aneurysms

Seven carotid cave aneurysms were studied with various imaging techniques and at surgery. The carotid cave aneurysm projects medially with most of it overlying the sella turcica. The aneurysm partially overlies the anterior loop of the cavernous carotid artery and the anterior loop always partially overlies the sella turcica in these cases. The site of the cave aneurysm corresponds well with an area of the carotid artery observed on dissection studies which is adjacent to the sella. This parasellar area differs from the carotid cave in that it is below the dural ring and is not reinforced by the bone of the carotid sulcus. The findings explain the medial projection of the cave aneurysm in that this is the direction of least resistance which in turn also corresponds with the site of maximal force of the flowing blood.     

内镜下经鼻蝶入路治疗鞍区病变的解剖学研究

目的研究内镜下蝶窦和鞍区的解剖结构。方法对8例成人头颅标本在内镜下模拟经鼻蝶手术入路,解剖观察蝶窦后壁和鞍区。结果将蝶窦后壁“井”字线划分为九个区,中间从上到下分别为视交叉区、鞍区和斜坡区,两侧从上到下分别为视神经管区、鞍旁海绵窦区和斜坡旁海绵窦区。鞍型蝶窦后壁中常见的解剖标志有斜坡凹陷、视神经管隆突、颈内动脉隆突和视神经颈内动脉隐窝;其中视神经颈内动脉隐窝是恒定的骨性解剖标志,毗邻视神经、海绵窦、海绵窦内颈内动脉、眶尖;两侧视神经颈内动脉隐窝的连线是鞍结节的投影。鞍旁海绵窦区是骨缺损好发的位置。结论对蝶窦后壁的九分区法适用于骨质层、硬膜层和颅内层,使复杂的鞍区及附近结构相对简化,易于识别和定位;视神经颈内动脉隐窝是重要的解剖标志。     

Bacterial cavernous sinus aneurysm treated by detachable balloon technique

We describe a patient who developed bilateral cavernous sinus septic thrombosis secondary to a suppurative lesion on the left cheek. Despite clinical improvement, left oculomotor symptoms recurred suddenly. A carotid artery aneurysm within the cavernous sinus was diagnosed by means of magnetic resonance imaging and confirmed by digital angiography. Follow-up angiograms showed an initial decrease in the aneurysm size, with subsequent enlargement. A latex contrast-filled balloon was successfully placed within the aneurysm, preserving the carotid parent artery blood flow. Our case illustrates the usefulness of the detachable balloon technique in the treatment of bacterial aneurysms of the cavernous sinus as an alternative treatment to carotid artery ligation.     

A case of CNS aspergillosis developing orbital apex syndrome and causing mycotic aneurysm and the subsequent cerebral infarction]

A 79-year-old woman, with no immune deficit, had presented progressive visual disturbance, diplopia and ptosis of her left eye over 2 weeks. T1-weighted MR images with gadolinium showed a heterogeneously enhanced lesion extending from the left orbital apex along the optic nerve to the cavernous sinus. Although we could not detect fungus by a transsphenoidal biopsy, we suspected fungal infection because of high level of galactomanan antigen in serum. Despite antifungal chemotherapy, her symptoms did not improve. CT image on day 40 showed an aneurysm in the left internal carotid artery, on day 43 cerebral infarction in the left internal carotid artery distribution and on day 45 she died. Autopsy disclosed that aspergillus hyphae invaded the left sphenoid sinus, cavernous sinus and wall of the aneurysm. In this case, fungal infection in the frontal skull base including orbital apex caused mycotic aneurysm in the intracavernous portion of the left internal carotid artery. Skull base aspergillosis presenting orbital apex syndrome is itself rare and in addition, the occurrence of cerebral infarction in the mycotic aneurysm has hardly been reported. We should have cerebrovascular disease in mind as a complication of CNS aspergillosis.