THU101 A Challenging Case Of Recurrent Suprasellar Epidermoid Cyst With Visual Field Deficits

Abstract

Abstract Disclosure: S. Ahsun: None. A. Atri: None. R. Bhat: None. C. eaton: None. N. Blocher: None. A challenging case of recurrent suprasellar epidermoid cyst with visual field deficits. Introduction: Intracranial epidermoid cysts account for approximately 1% of all intracranial tumors. The most common location of occurrence is cerebellopontine angle. Suprasellar region is the second most common location. We present a case for suprasellar epidermoid cyst with visual field deficits. Case Presentation: A 52 y/o female presented to an ophthalmologist for blurring of vision and was found to have bitemporal hemianopia. MRI of the brain showed a large suprasellar mass of 6.9x4.2x3.3 cm with extension into the surrounding structures. A portion of the cyst wall was hemorrhagic. There was significant mass-effect on the optic chiasm and bilateral optic tracts. Patient underwent elective craniotomy with left frontotemporal approach. A characteristic pearly wide epidermoid capsule was visualized through the oculomotor triangle. The optic nerve was noted to be quite distorted in its course, exiting from the optic canal and being pushed superiorly by the epidermoid tumor. Accessible tumor capsule was resected, however due to the dense adhesions of the epidermoid cyst to the surrounding vasculature and the optic nerves, complete resection was not attempted. Postoperatively, patient developed right-sided hemiparesis due to an acute infarct. Patient also developed some dementia, hyperphagia and aggressive behavior following her surgery. She started her rehabilitation therapy but had persistent dementia and cognitive decline. Repeat vision testing showed right superior homonymous hemianopia. MRI of the brain a year after the initial surgery showed growth of the residual cyst and some obstructive hydrocephalus but without any symptoms. She underwent a second debulking procedure that was successful with complete excision of the residual tumor but the patient had delayed recovery. She subsequently underwent tracheostomy and PEG tube placement and was transferred to the rehabilitation facility. She is now awake but still nonverbal. Patient also developed panhypopituitarism and is currently on the replacement for cortisol and thyroid hormone. She is also on DDAVP for her diabetes insipidus which seems to be permanent in her case. Conclusion: This case highlights some important facts: 1. Epidermoid cysts are challenging from the management standpoint. Only 50-80% can be resected completely. Incomplete removal increases the chances for recurrence which are variable at 1-54%. 2. Even in cases of recurrent growth repeat surgery should only be performed if patient has significant symptoms from the tumor. 3.As per the literature patients with adjuvant radiotherapy have improved outcomes. As in our case radiotherapy should have been considered in the setting of recurrence of the tumor. 4.Endoscopic endonasal approach is a new modality that has shown a very low rate of complications after resection. Presentation: Thursday, June 15, 2023