A 58-year-old female presented with a sudden onset of headache and nausea. The patient had a 5-year history of hypertension, she had no smoking history and family history. Three years earlier, she had been diagnosed with a sellar tumor associated with a right visual field deficit, but she did not receive medical treatment. One day after the onset of severe symptoms, she was examined to find a significant loss of light perception and a degenerated optic disc in the right eye with a further ophthalmological examination. A head computed tomography (CT) scan showed diffuse subarachnoid hemorrhage (SAH) in the cistern magna and carotid cistern with a round-shaped calcified mass in the sellar area (Fig. 1a). Magnetic resonance imaging (MRI) revealed that the lesion was slightly well-enhanced with gadolinium, which was the characteristic of meningioma (Fig. 1b, c). Consequently, a tuberculum sellae meningioma was diagnosed and measured at 2.5 * 3.0 * 2.2 cm in size. The MRI provided the evidence of damage to the right optic nerve canal and the anterior clinoid process. The relationship between the aneurysms and the tumor was clearly showed in preoperative CT angiography (CTA) and MRI (Fig. 1d, e). The 3-dimensional digital subtraction angiography (DSA) indicated that the tumor was coexisted with a right paraclinoid ICA aneurysm and a left ICA bifurcation aneurysm (Fig. 2). During the DSA, Balloon Occlusion Test (BOT) was performed, and the result was positive. Based on the head CT and DSA imaging findings, an unruptured, left side aneurysm was proposed. Neuroradiologists considered that the small left ICA bifurcation aneurysm was inappropriate for endovascular intervention. On the other hand, according to the head CT and MRI scan results, the ICA and aneurysm on the right side was not wrapped in the tumor, and just be pushed out and down.
The patient underwent a right pterion craniotomy. Twenty percent mannitol 250 ml was intravenous dripped before we cut open the dura, so the intracranial pressure dropped and the right frontal lobe was retract. Then the sylvian fissure was completely split along the M1 and M2 segments of the middle cerebral artery. Part of the anterior clinoid process and platform of the sphenoid bone were grinded by drill, exposure plate of saddle tumor basal, the tuberculum sellae meningioma partly blocked the ICA and aneurysms, then, the tumor was decompressed with the help of CUSA (Cavitron Ultrasonic Surgical Aspirator; Sonoca300, Germany, Cicel), and removed piecemeal. Also the tumor grow into and damage the optic canal, the optic nerve, optic tract, and half of the chiasm on the right side has been reoriented from their original routes by the tumor, this part of tumor was exposed and removed by opening optic canal with a high-speed drill. The right ICA aneurysm was subsequently dissected and clipped after internal decompression of the meningioma (Fig. 3a, d). During the clipping, the right common carotid artery (CCA) and ICA was not exposed. We pressed the neck by hand for few minutes before the parent artery was blocked, and then the remaining tumor was removed, finally, according to the directionality of the left aneurysm, we dissected the opposite spaces in order to clip another aneurysm (Fig. 3b, e). After the surgery, head CT angiography demonstrated that both of the aneurysms were completely isolated, and the tumor was adequately resected.
The post-operative course was uneventful. One week after the operation, the patient was subsequently discharged without new neurological deficits. Her visual acuity did not change after the operation. The histopathological diagnosis suggested that the tumor was a mixed meningioma (WHO Grade I). Follow-up imaging was conducted at 6 months post-surgery (Fig. 4); there was no residual tumor or tumor reoccurrence, whereas there was a fully occluded aneurysm.