PMC9899474_01
(a) Non-contrast computed topography head suggests hemorrhage in the pituitary gland and interhemispheric fissure with hypodensities in the bilateral medial frontal lobe suggesting infarct; (b) T2 axial MRI suggests a hyperintense lesion in the isointense pituitary gland and hyperintensity in the medial frontal lobe with bilateral loss of sulci and gyri pattern suggestive of the infarct; (c) MR arteriography suggests an aneurysm at the left A1-Acom junction with no visualization of proximal and distal anterior cerebral artery suggestive of diffuse spasm. RPS: Right posterosuperior; LAI: Left Anteroinferior.
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F1
On radiological evaluation, the initial NCCT head revealed a subarachnoid hemorrhage in the interhemispheric fissure and evidence of bleeding in the pituitary gland [Figure 1a]. MRI brain was soon done, which showed an infarct and hemorrhage in the pituitary gland; there was an evidence of an infarct in the bilateral medial frontal gyrus, basal ganglia, and supplementary motor area [Figure 1b]. MR arteriography revealed an aneurysm at the left A1-anterior communicating artery (Acom) junction directed superomedially with diffuse spasm in a bilateral anterior cerebral artery (ACA) [Figure 1c].
(a) Preoperative digital subtraction angiography (DSA) showing anterior communicating artery (Acom) aneurysm at the junction of the Acom and left A2 with distal vessels narrow in caliber, suggesting vasospasm (black arrow); (b) postoperative DSA showing clipped aneurysm with diffuse vasospasm of bilateral A2, Left A1, and middle cerebral artery vessels (white arrow); (c) postoperative DSA following vasodilation by intraarterial microcatheter injection of nimodipine revealing persistent vasospasm (white arrow); (d) postoperative DSA of the right internal carotid artery suggestive of persistent vasospasm more in anterior cerebral artery branches than right middle cerebral artery (black arrow).
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F2
Intraarterial spasmolysis by microcatheter in the bilateral internal carotid artery (ICA) was tried without much improvement in vascular spasm [Figures 2a-d].
(a) Postoperative MRI brain with diffusion-weighted sequence suggests restriction diffusion in the bilateral frontal lobe, and basal ganglia region suggestive of the infarct; (b) microscopic sections show a hypercellular tumor composed of solid sheets, nests, and trabeculae. Tumor cells contain scant granular eosinophilic cytoplasm, round nuclei inconspicuous nucleoli; (c) Hematoxylin-Eosin staining of the pituitary macroadenoma revealing hemorrhagic necrosis pattern and extensive tumor coagulative necrosis, consistent with recent hemorrhagic infarction; (d) immunohistochemical results for pituitary hormones show negative staining for growth hormone, leutinising hormone, thyroid stimulating hormone, adreno corticotrophic hormone (GH, LH, TSH, and ACTH); Prolactin immunostains suggest nonfunctional pituitary macroadenoma.
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F3
The postoperative MRI brain revealed a bilateral diffuse infarct [Figure 3a]. Postoperative histopathology revealed blood clots intermixed with tumor tissue on hematoxylin and eosin (H&E) staining and no staining on immunohistochemistry for prolactin, growth hormone, and adreno corticotrophic hormone (ACTH) [Figures 3b-d].