Presentation
Visual failure.
Patient Data
Non contrast axial images through the brain demonstrate a large peripherally calcified mass in the suprasellar region. It is hyperdense.
In the suprasellar region, anterior to the pituitary is a 19 x 21 x 18mm rounded mass with heterogeneous lamellated internal signal (predominantly high T1 and very low T2) consistent with a thrombosed aneurysm. Posterosuperiorly flow void is noted consistent with a patent aneurysm 8 x 6 x 6mm arising from the ACA / Acom complex. The dome of the thrombosed aneurysm presses down on both optic nerves, more so on the left. Edema is present in gyrus rectus on the right. Chronic small vessel ischemic change is seen elsewhere.
CTA of the circle of Willis demonstrates a giant peripherally calcified ACA/Acom aneurysm. It is mostly thrombosed with a central lumen much smaller than the outer sac.
The patient went on to have angiography to fully characterized the arterial anatomy.
Via a right groin approach (5 F sheath) bilateral CCA and left vertebral artery angiography was performed, with 3 D rotational angiography of the left CCA. (only left ICA injections shown)
A peanut shaped ACOM aneurysm fills from the left CCA runs. It points anterolaterally to the right. It measures 12.5mm in its longest axis, 5.5mm across the body with a 5.5mm neck. Both A2 origins arise from the aneurysm base. Right A1 of good caliber.
Case Discussion
This patient went on to have a craniotomy and clipping and resection of the aneurysm.
Thrombosed pituitary region aneurysms are relatively common and usually pose no problem in diagnosis. Occasionally however a thrombosed aneurysm can have unusual signal characteristics and may be mistaken for a solid or cystic mass such as a craniopharyngioma. Clearly, such a mistake can have disastrous consequences, particularly if transsphenoidal surgery is performed. As such a healthy habit to adopt is to ask oneself the question "could this be an aneurysm?" for all pituitary region masses.
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