Transnasal Resection of an Adrenocorticotropic Hormone-Secreting Adenoma and Clipping of a Paraclinoid Aneurysm: Two-Dimensional Operative Video

Although pituitary adenomas and intracranial aneurysms often coexist,¹ the locations of these lesions rarely affect surgical planning. In such cases, however, a simultaneous (rather than staged) approach avoids multiple procedures or delays in treating the dominant pathology. Building on limited prior reports of transnasal aneurysm clipping,^2-6 we describe simultaneous transnasal treatment of an adrenocorticotropic hormone-secreting adenoma and a paraclinoid aneurysm in a 35-year-old woman (Video 1). The patient presented with weight gain, cutaneous striae, and fatigue, with endocrinologic testing notable for elevated adrenocorticotropic hormone and midnight salivary/24-hour urinary free cortisol. Imaging demonstrated a possible microadenoma. Petrosal sinus sampling confirmed the diagnosis and left laterality and identified a 3.0 × 2.7 × 2.2 mm left inferomedial paraclinoid internal carotid artery aneurysm with erosion through the bone into the sphenoid sinus. A transnasal approach to both lesions was planned given the proximity of the lesions, the inaccessibility of the aneurysm transcranially, and the likelihood of needing a stent or flow diverter with endovascular treatment that would delay treatment of the Cushing disease. An endoscopic endonasal approach was used for uneventful adenoma resection. The medial wall of the cavernous sinus was opened sharply to expose the carotid artery and aneurysm. Clipping was completed during an adenosine pause despite limited degrees of freedom. Postoperatively, the patient developed transient diabetes insipidus and hydrocortisone dependence but was neurologically intact and eupituitary on follow-up. With sufficient transnasal and vascular surgical experience, transnasal clipping of aneurysms can be safely performed in very selected cases. The patient consented to the procedures and publication.