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Background
Giant cavernous internal carotid artery (ICA) aneurysms mimicking pituitary tumors and causing pituitary dysfunction are rare but well documented. 1-7 It is estimated that they are the cause of hypopituitarism in about 0.2% of patients. 5 Open surgical options offer definitive treatment of these aneurysms as well as decompression of the pituitary gland; however, they are often technically challenging and carry many risks inherent to open surgery. Conventional endovascular treatment of coiling with or without stenting is a less invasive option, but it fails to achieve pituitary decompression. With the advent of flow diverters such as the Pipeline Embolization Device (PED; Covidien, Mansfield, Massachusetts, USA), the Silk stent (Balt, Montmorency, France) and the newest flow-diverting stents including Surpass (Stryker Neurovascular, Fremont, California, USA) and FRED (Microvention, Tustin, California, USA), neuroendovascular surgeons are equipped with another powerful tool with which to treat these complex cerebral aneurysms.
We report our experience with the use of Surpass flow-diverting stents (currently under investigational use in the SCENT trial) to successfully treat an unruptured giant cavernous ICA aneurysm causing panhypopituitarism (without diabetes insipidus) with subsequent full recovery of pituitary function after treatment. To our knowledge, this is the first report of complete recovery of pituitary function after endovascular treatment of a giant cavernous ICA aneurysm using a flow-diverting stent.
Case presentation
A 56-year-old man presented with impotence and generalized fatigue for 3 months. Physical examination was unremarkable with no visual deficit on ophthalmology examination. Endocrine investigation showed hypopituitarism with markedly decreased levels of 08:00 cortisol, testosterone and insulin-like growth factor 1 and low normal free thyroxine with normal thyroid-stimulating hormone ( table 1 ). There was no evidence of diabetes insipidus. The patient was started on hydrocortisone, topical testosterone and levothyroxine for his pituitary insufficiency. MRI was obtained for panhypopituitarism investigation and showed a large well-circumscribed enhancing sellar mass with a significant mass effect on the pituitary gland; subsequent CT angiography showed a giant right cavernous ICA aneurysm ( figure 1 ). After careful evaluation, an endovascular approach using Surpass flow-diverting stents was deemed to be the most appropriate treatment.
Table 1
Endocrine panel | Pre-procedural | Reference* | Post-procedural[dagger] | Reference |
FSH | N/A | 1.2-8.6 | 3.3 | 1-10 |
LH | 0.8 | 1-10 | 2.5 | 1-10 |
Total testosterone | 33 | 175-780 | 833 | 250-1100 |
Free testosterone | 3 | 50-247 | 69.9 |