Subarachnoid haemorrhage associated with pituitary apoplexy and radiographically occult supraclinoid internal carotid artery aneurysms

In patients with pituitary adenomas, incidental intracranial aneurysms have been documented. Previous studies have highlighted the importance of preoperative imaging in these patients. However, imaging may be limited and fail to show the presence of vascular abnormalities. In this report, we discuss a case of a man in his 30s presenting with a newly diagnosed pituitary adenoma. CT and MRI, on admission, showed a pituitary mass with extension into the right cavernous sinus. After a sudden neurological deterioration, emergent CT/CT angiography revealed pituitary apoplexy with subarachnoid extension without vascular abnormalities. Successful emergency transsphenoidal hypophysectomy was followed by digital subtraction angiography which revealed the presence of two right supraclinoid internal carotid artery aneurysms. With this case, we aim to highlight the need for further vascular imaging in patients with pituitary apoplexy and subarachnoid haemorrhage, as preoperative imaging may be negative for vascular abnormalities especially in the setting of cavernous sinus invasion.