Letter to the Editor
Hypopituitarism secondary to giant aneurysm of internal carotid artery
Hipopituitarismo secundario a aneurisma gigante de la arteria carótida interna
Carmen María Cano de Luque
, Ángel Manuel Molino González, Andrea Valcárcel Alonso
Corresponding author
Servicio de Medicina Interna, Hospital Clínico San Carlos, Madrid, Spain
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The arrow points to a giant aneurysm of the internal carotid artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Internal carotid artery aneurysms have a low prevalence, and their clinical presentation is determined by the anatomical location of the mass. Projection toward the intrasellar region occurs in 1%–2% of cases, and hypopituitarism due to pituitary gland compression is a rare entity reported in the medical literature in very few case series.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this paper we present the case of a 62-year-old woman, with no remarkable medical history, who visited the Emergency Department due to experiencing a 48-h history of vomiting and epigastric pain. In addition, she reported a three-month history of an overall deteriorated condition, asthenia, and holocranial headache, as well as decreased visual acuity over the past year.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The most remarkable findings of the physical examination were arterial hypotension and bitemporal hemianopia. A chest X-ray and electrocardiogram revealed normal findings. Given that the blood tests showed severe hypoosmolar hyponatremia and mild hypokalemia, a hormonal study was also requested, obtaining a diagnosis of panhypopituitarism (secondary hypothyroidism with decreased free T4 levels; normal thyroid stimulating hormone levels; and decreased cortisol, adrenocorticotropic hormone, luteinizing hormone, and follicle-stimulating hormone levels).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Considering the initial suspected diagnosis of a pituitary macroadenoma, a brain magnetic resonance imaging (MRI) scan was performed, detecting a giant aneurysm of the supraophthalmic internal carotid artery with compression at the level of the pituitary gland and the optic chiasm. This study was completed with a cerebral arteriography that confirmed the diagnosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). An ophthalmology evaluation was also requested, including a visual campimetry that confirmed the existence of predominantly left-sided bitemporal hemianopia.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient’s case was presented during a meeting held with the Neurosurgery and Neuroradiology Committee, where it was decided to schedule an aneurysm exclusion procedure with a Pipeline™ stent. This procedure was completed without complications, except for the appearance of a small subarachnoid hemorrhage that was viewed in a follow-up computed tomography (CT) scan and resolved with conservative management. Dual antiplatelet therapy and hormone replacement therapy with hydrocortisone and levothyroxine was subsequently started. One month after the procedure, the patient had to be taken to the Emergency Department by the Emergency Care Services due to developing a massive subarachnoid hemorrhage secondary to rupture of the aneurysm. She was consequently admitted to the Intensive Care Unit, where encephalic death was confirmed and she eventually passed away.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Intracranial aneurysms are rare, with a prevalence ranging from 0.4 to 6 cases per 100 inhabitants according to different studies.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most are found in the junction of the carotid artery and the posterior communicating artery, in the anterior communicating artery, or at the level of the bifurcation of the middle cerebral artery.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Their most common clinical presentations are subarachnoid hemorrhage, cerebral ischemia, or pseudotumor syndromes. The clinical manifestations of the latter are determined by the anatomical location of the mass, with headache and visual alterations being common, although most patients remain asymptomatic.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Rarely, when an intracranial aneurysm extends into the sellar region (1%–2% of intracranial aneurysms), it may present as hypothalamic-pituitary axis dysfunction. This is a very rare cause of hypopituitarism described in case series published in the literature. A review of more than 4000 patients with hypopituitarism carried out over four decades concluded that intrasellar aneurysm was the underlying etiology of this disorder in only 0.17% of these cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Hypopituitarism due to hypothalamic or pituitary gland compression is usually present at diagnosis, and is often irreversible despite treating the aneurysm.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Visual involvement is observed in aneurysms with a minimum size of 2.7 cm.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In some cases, the aneurysm thromboses or forms a carotid-cavernous fistula, which may delay its expansion. Aneurysm rupture occurs in approximately 15% of cases.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The differential diagnosis usually includes neoplastic processes, mainly pituitary adenomas, craniopharyngiomas, and gliomas, as well as infiltrative processes, such as sarcoidosis or histiocytosis. Adequate differentiation between an aneurysm and other entities is essential, as the therapeutic approach for each condition varies and a diagnostic error could have disastrous consequences. The diagnostic tests of choice are brain MRI and arteriography, the latter being the gold standard. An MRI scan of an aneurysm shows a halo image generated by the two dural layers that line the cavernous portion of the carotid artery. In case of thrombosis, filling defects may also be observed within the mass. In the event of doubts, an arteriography should be performed to confirm the diagnosis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding the treatment of intrasellar aneurysms, endovascular therapeutic options are the method of choice, with the neurosurgical approach being reserved for exceptional cases.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, our case corresponded to a rare and potentially lethal condition that can manifest in a non-specific manner and requires a high degree of suspicion for its correct diagnosis and treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cano de Luque CM, Molino González ÁM, Valcárcel Alonso A. Hipopituitarismo secundario a aneurisma gigante de la arteria carótida interna. Med Clin (Barc). 2021;157:e329–e330.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1505 "Ancho" => 1508 "Tamanyo" => 169638 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Arteriography image. 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