Extract

An 82-yr-old woman was hospitalized with a serum sodium of 118 mmol/liter after 2 months of fatigue, anorexia, nausea, constipation, and weight loss. Hydrochlorothiazide was discontinued. After iv normal saline, her hyponatremia resolved. A cosyntropin stimulation test revealed adrenal insufficiency. Subsequent pituitary evaluation demonstrated central hypothyroidism and hypogonadism, as well as hyperprolactinemia.

Magnetic resonance imaging (MRI) and computed tomography angiogram (CTA) showed an intrasellar 2.0-cm left cavernous internal carotid artery aneurysm, compressing the pituitary gland and abutting the optic chiasm (Fig. 1). Formal visual field testing was recommended, as should be done with any sellar mass adjacent to the chiasm.

Although surgical or interventional radiological approaches have been used for sellar aneurysms, our neurosurgical consultant advised conservative management based on a minimal risk of intracranial hemorrhage. The aneurysm was stable by CTA at 6 months. Glucocorticoid replacement preceded thyroid hormone therapy (to prevent precipitating adrenal crisis) and resulted in dramatic clinical improvement. Diabetes insipidus did not develop.

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