Unusual site of carotid aneurysm.

Mrs LG a 60-year-old woman was referred to the medical outpatient department by her general practitioner with a 2-month history of increased tiredness, lethargy and weight loss having lost approximately 2 stones in the preceding 5 months. She had been diagnosed with hypothyroidism a few years previously and had been on thyroxine intermittently. She was not on thyroxine when seen in clinic. Blood tests carried out by her general practitioner indicated a free T4 6.7 pmol/l (12–22), thyroid stimulating hormone (TSH) 6.3mU/l (0.5–4.5) and prolactin 1965 u/l (<650), sodium 139mmol/l (135–145), potassium 5.1mmol/l (3.5–5.1) and eGFR 57ml/min. In the clinic she also complained of generalized myalgia, arthralgia and constipation. There was no history of cold intolerance or hair loss. She also did not give a history of headaches, visual disturbance or galactorrhoea. She was post menopausal with her periods having stopped 10 years earlier and had incidentally been diagnosed with primary biliary cirrhosis many years previously which had been stable and her medications included ursodeoxycholic acid and atenolol. She had a family history of thyrotoxicosis and her sister had died of a ruptured cerebral artery aneurysm 10 years earlier. On examination she had a pulse of 64 bpm and BP 120/70mm of Hg. There was reduced visual acuity in her left eye, which had been longstanding with no abnormality on visual field testing on confrontation. Cardiovascular, respiratory and abdominal systems were normal. Her repeat blood tests from the clinic were as show in Tables 1–3. She underwent a repeat short synacthen test which indicated basal cortisol 83 nmol/l and a 30min post-adreno cortico tropic hormone (ACTH) level 313 nmol/l. Hydrocortisone 10mg twice a day was started and an magnetic resonance imaging (MRI) of pituitary gland and formal visual field testing were requested. Formal visual field testing were within normal limits and the MRI was reported to show a large well defined lesion in the sella extending to the suprasellar compartment but not extending to the optic chiasm with the presence of a flow artefact. A subsequent MR angiogram demonstrated a very substantial aneurysm arising from the internal carotid artery at the level of the sella containing thrombus. She was referred to neurosurgery and underwent further CT angiogram to delineate the margins of the aneurysm. She was then assessed by interventional radiology and had endovascular coil embolization without complications. At her last clinic appointment she appeared well and had put on weight. As her FT4 levels were still low she was commenced on thyroxine. She is due to be followed-up by the neurosurgical department for repeat MRA 6 months post-procedure.