Simultaneous endoscopic endonasal treatment of a GH-secreting PitNET and paraclinoid aneurysm in a hybrid operating room – 2D operative video

Background: The coexistence of pituitary neuroendocrine tumor (PitNETs) and paraclinoid aneurysms is uncommon but clinically significant due to the risk of intraoperative rupture during transsphenoidal surgery. Hybrid operating rooms and advances in endoscopic endonasal techniques now permit the simultaneous treatment of both lesions in selected patients. Case Description: We present the case of a 61-year-old female who presented with progressive acral enlargement and intermittent headache. Neurological examination was unremarkable. Neuroendocrinological evaluation revealed elevated age-adjusted serum insulin-like growth factor 1 and growth hormone (GH) levels with preserved anterior pituitary function. Contrast-enhanced magnetic resonance imaging demonstrated a sellar mass consistent with a PitNET; within the lesion, a focal flow void suggested a vascular structure. Computed tomography angiography confirmed a left superior hypophyseal artery aneurysm projecting ventromedially into the sellar region. Given the risk of aneurysm rupture during tumor resection, we elected to perform simultaneous treatment of both lesions though an endoscopic endonasal approach in a hybrid operating room. The procedure included proximal balloon occlusion of the cavernous segment of the internal carotid artery, roadmapping-assisted clipping under direct endoscopic visualization, and intraoperative angiographic confirmation of aneurysm obliteration. Following aneurysm exclusion, gross total resection of the GH-secreting PitNET was achieved. The patient experienced an uneventful postoperative recovery. At 3-month follow-up, she demonstrated biochemical remission of acromegaly. Imaging confirmed complete aneurysm occlusion and total tumor resection. Conclusion: This case highlights the feasibility of simultaneous endoscopic endonasal aneurysm clipping and tumor resection in a hybrid operating room, avoiding staged procedures and minimizing morbidity. Close collaboration between surgical and endovascular teams is essential to optimize outcomes.