Suprasellar giant aneurysm

Case contributed by A.Prof Frank Gaillard

Presentation

Visual failure.

Patient Data

Age: 80 years
Gender: Female
CT

CT brain

Non contrast axial images through the brain demonstrate a large peripherally calcified mass in the suprasellar region. It is hyperdense. 

MRI

MRI brain

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. Oedema is present in gyrus rectus on the right. Chronic small vessel ischaemic change is seen elsewhere. 

CT

CTA COW

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 characterised the arterial anatomy.  

DSA (angiography)

Cerebral angiography

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 calibre.

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 transphenoidal 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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Case information

rID: 17175
Case created: 23rd Mar 2012
Last edited: 16th Nov 2016
Inclusion in quiz mode: Included

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