Cranial Nerve Palsy Research Articles (Page 1)

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis (LCH) marked by systemic involvement and diverse clinical manifestations. We report a 35-year-old man with yellowish-brown periorbital lesions initially diagnosed as xanthelasma, which later recurred. The patient developed neurological symptoms, including proximal lower limb weakness and cranial nerve palsies, which improved with corticosteroids. Imaging revealed retro-orbital masses, pan-rhinosinusitis and extensive sclerosis of the sinonasal cavity, along with systemic organ involvement, including the kidneys and spine. Histopathology demonstrated foamy histiocyte infiltration, positive for CD163 and CD68 but negative for S100. The BRAF V600E (B-raf proto-oncogene valine-to-glutamic acid substitution at position 600) mutation was absent. A multidisciplinary team initiated the LCH III protocol, leading to partial regression of cutaneous lesions and stabilisation of neurological symptoms. This case highlights the importance of recognising atypical ECD presentations and suggests the LCH III protocol may benefit BRAF-negative cases. Multidisciplinary management is critical given the disease's progressive, multisystem nature.

The purpose of this study was to evaluate the association between glycaemic status and the incidence of third, fourth, and sixth cranial nerve palsy (CNP). This is a retrospective nationwide population-based cohort study using South Korean National Health Insurance Service (NHIS) data since 2009. Health check-up data of 4,067,842 individuals aged from 20 to 90 years in the period from 1 January 2009 to 31 December 2018 were analysed. The subjects were classified according to glycaemic status as follows: non-diabetes, impaired fasting glucose (IFG), newly detected diabetes, diabetes duration <5 years, and diabetes duration ≥5 years. The primary endpoint of this study was the incidence of third, fourth or sixth CNP. Hazard ratio (HR) and 95% confidence interval (CI) of CNP were estimated using Cox proportional hazards regression analysis. In Model 5, we adjusted for age, gender, smoking status, alcohol consumption, physical activity, body mass index, hypertension, dyslipidaemia, and chronic kidney disease. During the follow-up period (mean, 6.3 years), 5835 cases of third, fourth, or sixth CNP were identified with 4,062,007 control cases. In the adjusted model 5, the adjusted HR for third, fourth, and sixth CNP in the IFG group was 1.098 (95% CI 1.030 - 1.171); in the newly detected diabetes group, 1.779 (95% CI 1.587-1.994); in the diabetes duration <5 years group, 1.921 (95% CI 1.731-2.131); and in the diabetes duration ≥5 years group, 2.571 (95% CI 2.343-2.820). Using the Kaplan-Meier curve, the log-rank test demonstrated an increase in the incidence of CNP proportional to the duration of diabetes (p < 0.001). This large-scale, population-based cohort study suggests that the risk of third, fourth, and sixth CNP significantly increased in patients with IFG and diabetes compared to those with normal glycaemic status.

Sixth cranial nerve palsy is the most frequent of the oculomotor palsies and may result from diverse etiologies, including intracranial or nasopharyngeal tumors. We report the case of a 36-year-old man in whom sixth nerve palsy was the initial manifestation of an undifferentiated carcinoma of the nasopharynx (UCNT). This case highlights the importance of ophthalmologic signs as a potential clue for early diagnosis of nasopharyngeal carcinoma.

To investigate the impact of long-term abnormal head position on internal carotid artery (ICA) and external carotid artery (ECA) flow patterns in patients with unilateral congenital fourth nerve palsy. This study was conducted in a tertiary clinic and involved 29 patients with congenital fourth cranial nerve palsy, with a vertical deviation greater than 14 prism diopters. Demographic information, clinical presentations, and ophthalmological findings were reviewed, and carotid Doppler ultrasound measurements were compared. The mean age of the patients was 21.4 ± 10.9 years, with 16 females and 13 males included in the study. The vertical deviation of the cases ranged from 14 to 35 prism diopters (PD), with a median deviation of 22 PD. ECA and ICA diameters were significantly lower on the non-paralytic side compared to the paralytic side (P = .001 and .008), whereas resistive index values were higher on the non-paralytic side (P = .009 and .011). A strong positive correlation was found between the angle of deviation and age (r = 0.685, P < .001), and a negative correlation was noted between carotid flow velocities and angle of deviation (r = -0.546 to -0.626, P < .001). In patients with congenital fourth nerve palsy, long-term abnormal head position may alter carotid artery flow, reducing vessel diameter, and increasing resistive index on the non-paralytic side. These changes may contribute to complications, suggesting that timely surgical intervention might help prevent carotid flow alterations, facial asymmetry, and musculoskeletal issues.

Differences in clinical profiles of patients with symptomatic and asymptomatic apoplexy in pituitary neuroendocrine tumors.

Manipulation of the Lower Cranial Nerves and Superior Jugular Bulb During Subtotal Temporal Bone Resection for Advanced Temporal Bone Malignancies: Anatomical Considerations and Surgical Strategies.

Disclosure: B. Biagetti: None. E. Cordero Asanza: None. M. Araujo Castro: None. C. Pérez-López: None. R. Camara: None. C. Lamas: None. E. Martinez Saez: None.Background Pituitary apoplexy (PA) is a rare and potentially life-threatening condition resulting from hemorrhage or infarction of the pituitary gland. This study aimed to assess clinical characteristics, management, and outcomes of PA in patients aged <65 and ≥65 years using data from a Spanish multicenter cohort. Methods We conducted a retrospective, multicenter study (2010–2023) of 301 PA patients from 18 Spanish hospitals. Data were analyzed for differences in demographics, clinical presentation, treatment approach, and outcomes. Results Patients aged ≥65 years (n=116, 38.5%) had more comorbidities, diabetes (11.4 vs. 34.5%; p<0.01), hypertension (29.7 vs. 79.3%; p<0.01), dyslipemia (32.4 vs. 62.9%; p<0.01) and cardiovascular disease (4.3 vs. 27.6%; p<0.01), compared to younger patients (n=185, 61.5%). No significant differences were observed in clinical presentation, including Pituitary Apoplexy Score and radiological findings except for higher frequency of cranial nerve palsy (46.2 vs. 64.9%; p=0.02) more frequent in older patients. Surgical (n=209), and conservative (n=92) treatment rates were similar between groups (conservative: 29.9 vs. 32.8%; p=0.51). Histopathological analysis revealed more necrosis in patients aged ≥65 years (66.7 vs. 80.6%; p = 0.04). Surgical resection rates and outcomes including mortality were comparable across age groups. Conclusions PA management and outcomes were comparable in younger and older patients, despite greater comorbidities and more severe symptoms in older individuals. Histopathological findings suggest potential age-related differences in tumor biology, warranting further research. MRI would be preferred for diagnosis, particularly in older patients, as ischemic necrotic PA may be ruled out without advanced imaging.Presentation: Saturday, July 12, 2025

Disclosure: K. Winnicki: None. Z.A. Ahmed: None. G. Olson: None. T. Porter: None.Background: The differential of a sellar mass is broad, and prior clinical history is important to take into consideration when formulating a differential diagnosis. Case: A 53 year-old gentleman with a history of multiple myeloma in remission who had undergone an autologous stem cell transplant within the last two years presented for several days of intermittent diplopia. Given the acuity of symptoms, an MRI was performed and revealed a T1-T2 isointense lesion in the right half of the sella extending into the right cavernous sinus with relative hypoenhancement compared to the pituitary gland; leftward deviation of the infundibulum was also noted. Functional testing revealed an 8am cortisol of 11.5 ug/dL (3.7-19.4 ug/dL) with ACTH of 8.8 pg/mL (7.2-63.3 pg/mL), free T4 0.9 ng/dL (0.7-1.5 ng/dL) with TSH 1.898 uIU/mL (0.350-4.940 uIU/mL), LH 5.1 mIU/mL (.57-12.07 mIU/mL), FSH 15.8 mIU/mL (1-10 mIU/mL), random total testosterone 185 ng/dL (264-916 ng/dL), and prolactin 21 ng/mL (3-19 ng/mL). Two days later the patient was noted to have a mild right abduction palsy. Given symptoms and history of multiple myeloma, the patient underwent endoscopic endonasal subtotal resection of the sellar lesion. Upon incision of the dura, a firm, white fibrous material with a gelatinous portion in the sphenoid was noted. Pathology revealed cells with prominent nucleoli, enlarged nuclei, minimal perinuclear Hof region, and minimal cytoplasm; these cells were positive for CD138 and CD20 and negative for synaptophysin and cytokeratin 8/18, suggesting a plasmablastic morphology. Monoclonal free lambda light chains were noted on serum electrophoresis, and bone marrow biopsy revealed evidence of plasma cell neoplasm (most recent bone marrow biopsy eight months prior was without evidence of persistent disease). The clinical picture was most concerning for CNS relapse of the patient’s myeloma; he received five fractions of radiation therapy to the right cavernous sinus, and was started on venetoclax, pomalidomide, and dexamethasone with plans to add carfilzomib in the future. Outpatient endocrinology follow-up was advised. Even in patients with known myeloma, such tumors are rare, and plasmacytomas are far less common than pituitary adenomas. Compared to pituitary adenomas, plasmacytomas have a greater propensity for cavernous invasion and parasellar bone erosion, including the cranial nerve foramina, contributing to a higher rate of cranial nerve palsies; one series of 31 patients found that 65% of patients with plasmacytomas had diplopia at presentation (1). Conclusion: Plasma cell tumors should be considered in the differential for lesions involving the sella, particularly in the presence of cranial nerve palsies. (1) DiDomenico J, Ampie L, Choy W, Lamano JB, Oyon DE, Kesavabhotla K, Bloch O. Sellar plasmacytomas masquerading as pituitary adenomas: A systematic review. J Clin Neurosci. 2018 Apr;50:20-23.Presentation: Monday, July 14, 2025

Disclosure: J. Aboytes: None. J. Loayza: None. I. Mollogon: None. I. Cantu: None.Introduction: Hypopituitarism is a condition where the pituitary gland produces insufficient hormones due to either impaired synthesis or disrupted transport. Pituitary tumors account for about 15% of intracranial tumors, with pituitary adenomas being the leading cause of hypopituitarism in adults. These tumors can be functional (hormonally active) or non-functional, with the latter being rare in children and most common in individuals aged 60-65. Non-functional adenomas often cause symptoms like visual field deficits, headaches, and hypopituitarism, with cranial nerve palsies occurring when the tumor extends into the cavernous sinuses. A rare but notable manifestation of pituitary adenomas is isolated oculomotor (third nerve) palsy. This report highlights such a case where third nerve palsy was the first sign of a non-functional pituitary adenoma. Case: A 46-year-old man with uncontrolled type 2 diabetes presented with acute right-sided headache, diplopia, ptosis, and right leg weakness. His symptoms began with a headache that worsened throughout the morning. On examination, he had right-sided ptosis, a non-reactive right pupil, facial drooping, and weakness in his right leg. Given his symptoms, he received thrombolytic therapy, resulting in partial improvement of his leg weakness, but the right eye pain and diplopia persisted. A CT scan showed no acute ischemic or hemorrhagic events but revealed a right-sided mass near the sella. Further imaging with MRI confirmed a 2.1 cm tumor affecting the optic chiasm and invading the right cavernous sinus, with no infarction or hemorrhage.Laboratory results showed signs of hypopituitarism and a hemoglobin A1c of 11.1%. ACTH: 55.5 pg/mL (Reference: 7.2-63.3), Cortisol: 4.1 µg/dL (Reference: 5.0-25.0), TSH: 0.196 µIU/mL (Reference: 0.358-3.740), Free T4: 0.64 ng/dL (Reference: 0.76-1.46), LH: 0.4 (Reference: 1.5-9.3), Prolactin: 0.9 ng/mL (Reference: 2.1-17.7), Growth Hormone: 0.1 (Reference: 0.0-10.0), IGF-1: 68 ng/mL (Reference: 81-263). He was treated with hydrocortisone, levothyroxine, insulin and atorvastatin. Neurosurgical consultation recommended surgery after stabilization, with follow-up scheduled post-discharge. Endocrinology follow-up was also scheduled. Discussion: Isolated third nerve palsy is a rare but important presentation of non-functional pituitary adenomas. This case emphasizes the need to include pituitary tumors in the differential diagnosis of cranial nerve deficits to prevent misdiagnosis and treatment delays. Given the potential for diagnostic anchoring bias, clinicians should maintain a broad perspective when assessing neurological deficits. Prompt imaging and endocrine assessment are essential for timely diagnosis and management, ensuring appropriate intervention before significant complications arise.Presentation: Monday, July 14, 2025

Objective: To describe the clinical characteristics and cerebrospinal fluid (CSF) changes in patients with Guillain-Barré syndrome (GBS) at the Neurology Center of Bach Mai Hospital. Subject: We selected 54 patients who were diagnosed with Guillain-Barré syndrome from July 1, 2024, to June 31, 2025, at Bach Mai Hospital. Methods: Cross-sectional descriptive study. Results:The study included 54 patients with Guillain-Barré syndrome, with a mean age of 51.2 years; males accounted for 55.6%. The most commonly affected age groups were over 60 years and 31–40 years. The most frequent antecedent event was respiratory tract infection (38.9%), with onset of neurological symptoms occurring within 6 weeks post-infection. The most common initial clinical manifestations were limb weakness (75.9%), cranial nerve palsy (20.4%), and dizziness (14.8%). The mean Medical Research Council (MRC) muscle strength score was 44.3 at admission, decreased to 34.7 during the acute phase, and improved to 50.1 at discharge. Albuminocytologic dissociation in CSF was observed in 81.4% of patients. The findings highlight that limb weakness is the predominant clinical feature, and albuminocytologic dissociation is a key paraclinical marker in the diagnosis of GBS. Conclusion:This study suggests that Guillain-Barré syndrome tends to occur more frequently in males than females. The most common initial symptoms are tetraparesis and cranial nerve involvement. Albuminocytologic dissociation in CSF was present in the majority of cases, reaffirming the diagnostic value of CSF analysis. Most patients experienced a favorable clinical course and good recovery following treatment, underscoring the effectiveness of current therapeutic interventions.

Strabismus, or squint or deviating eyes, is defined as misalignment of the eyes when fixating on an object and is a common problem in ophthalmology. Palsy of the third, fourth or sixth cranial nerve is one of the leading underlying causes for paralytic strabismus, often requiring surgery. However, uncertainty regarding factors influencing surgical success remains. Background/Objectives: The purpose of this study is to review the outcome and influencing factors of strabismus surgery in patients with cranial nerve palsy. Methods: A retrospective study of 57 patients with third cranial nerve (CN3) palsy, fourth cranial nerve (CN4) palsy, sixth cranial nerve (CN6) palsy or combined nerve palsy who underwent strabismus surgery between October 2009 and December 2023 was conducted. Analyzed data included demographic details, type of surgical intervention, etiology of nerve palsy, pre- and postoperative angle of deviation (AOD), vertical deviation (VD), best-corrected visual acuity (BCVA), and refractive error. Results: Mean age was 41.29 ± 23.14 years with a mean follow-up of 10.8 ± 15.38 months. 30 patients (52.63%) had CN6 palsy, 12 patients (21.05%) had CN3 palsy, eight patients (14.04%) had CN4 palsy and seven patients (12.28%) had combined nerve palsy. Brain neoplasm was the most common cause of nerve palsy (33.33%). Mean preoperative AOD improved from 17.54° ± 10.68 to 7.13° ± 8.93 and from 17.21° ± 9.58 to 7.49° ± 9.75 for near and distance, respectively (p < 0.001). Changes in VD, refractive error, and BCVA were not statistically significant. Conclusions: Age, gender, preoperative AOD, subtype and etiology of nerve palsy had no significant influence on surgical outcomes, which are satisfactory in patients with cranial nerve palsy (80.7%).

Objectives: To identify demographic, clinical, and operative factors of unplanned 30-day readmission following endoscopic transsphenoidal surgery (ETS). Design: Single-center retrospective study. Setting: Tertiary academic medical center based in New York, NY. Participants: A total of 386 adult patients who underwent nonemergent ETS for pituitary adenomas between March 2009 and May 2020. Main Outcome Measures: The primary outcome was 30-day unplanned hospital admission. Clinical and demographic characteristics were analyzed using χ2- and student t-tests. For factors with p-value &lt; 0.1, multivariate logistic regression models were constructed to estimate the adjusted odds of 30-day readmission across predictive factors. Results: Of 386 patients who received ETS, 29 (7.5%) patients required readmission within 30 days of discharge. Eleven (2.8%) patients were readmitted for complications related to electrolyte derangements (SIADH, hyponatremia), followed by 5 (1.3%) patients with epistaxis. On multivariate analysis, pituitary microadenomas (p=0.032), transient diabetes insipidus (p=0.021), and preoperative visual cranial nerve palsies (CN III/IV/VI; p=0.019) were associated with increased odds of 30-day readmission. Conclusions: Patients with pituitary microadenomas, transient diabetes insipidus, and preoperative cranial nerve palsies were at an increased risk for unplanned 30-day readmission after ETS. Dedicated neuro-endocrinology involvement is necessary in the postoperative period to reduce readmission risk in these patients. Identification and careful monitoring of these at-risk populations is necessary, as targeted post-discharge care may prevent readmission and improve both patient and hospital outcomes.

Middle meningeal artery (MMA) embolization is increasingly utilized in the treatment of chronic subdural hematoma (cSDH); however, supply cost variation between embolization agents remains unclear. We hypothesized that nBCA might be associated with lower costs, given the ability to use a single vial and treat multiple pedicles. To compare the supply costs of MMA embolizations using ethylene vinyl-alcohol copolymer-based Onyx (Onyx), n-butyl cyanoacrylate-based TRUFILL (nBCA), and/or coils. This retrospective study analyzed 100 consecutive MMA embolizations performed at a single institution before March 2025. The supplies (including catheters and embolic agents) used in each embolization, along with procedure time, laterality, and number of pedicles embolized, were documented. Radiographic and clinical patient outcomes were evaluated. Of the 100 procedures: 63 used nBCA, 26 Onyx, 2 coils, 2 nBCA and coils, and 7 Onyx and coils. Supply costs ranged from approximately $5000 to $18 000. Onyx was significantly less expensive than nBCA in supply cost per patient ($7910 vs $10 241; P<0.0001), cost per side ($6467 vs $7857; P=0.010), and cost per pedicle ($4375 vs $5369; P=0.012). Mean cost per patient was highest for nBCA and coils ($13 541 ± $1331), Onyx and coils ($12 364 ± $3259), and coils alone ($11 058 ± $1144). There were no significant differences in short-term complications (stroke, seizure, cranial nerve palsy, retreatment, hospital readmissions; P>0.05), functional outcomes (modified Rankin Scale; P=0.813), or complete cSDH resolution (P=0.149) between embolic techniques. There is significant variation in supply cost associated with different MMA embolization techniques. In our institutional experience, Onyx was associated with the lowest supply cost per patient, hemisphere, and pedicle. Complication rates and functional status did not significantly differ across techniques.

Necrotizing otitis externa (NOE) is a severe infection with potential skull base involvement. The role of fungal pathogens and the need for antifungal treatment remain controversial. We aimed to evaluate clinical characteristics, diagnostic challenges, and microbiology results in fungal NOE and assess considerations for antifungal therapy. This retrospective cohort study was conducted at two tertiary centers. NOE patients, based on clinical and radiological findings, were retrospectively reviewed. Clinical characteristics, microbiological findings, and disease persistence were compared between patients categorized by antifungal treatment status: Combined antifungal-antibiotic therapy versus antibiotic therapy alone. Of 125 patients, 25 received combined treatment (13 as initial treatment and 12 after persistent disease) and 100 received antibiotics alone. Combined treatment patients were younger, had prolonged symptoms, and more cranial nerve palsy, requiring longer treatment for persistent and aggressive disease. Fungi were found in 72% of combined-treatment cultures, but most were deemed unreliable by infectious diseases specialists, inconsistently leading to antifungal therapy. Antifungal therapy decisions in NOE lack standardization. We propose a protocol incorporating clinical and microbiological data to guide antifungal therapy. Prospective studies are needed to validate this protocol and establish standardized guidelines for fungal NOE treatment.

Abstract BACKGROUND Clival involvement by primary or secondary diffuse large B-cell lymphoma (DLBCL) is extremely rare and may mimic other skull base tumors such as chordomas or metastases. Due to its anatomical location, lesions in this area may initially present with cranial neuropathies, often delaying diagnosis and treatment. MATERIAL AND METHODS We report the case of a 43-year-old woman with no prior medical history who presented with binocular diplopia due to right sixth cranial nerve palsy, in the absence of systemic symptoms. Brain magnetic resonance imaging (MRI) revealed a right-predominant clival infiltrative lesion extending ventrally and caudally into the petrous apex and Meckel’s cave, with mild T2 hyperintensity, heterogeneous enhancement, absent bone remodeling, and involvement of cranial nerves V, VI, IX, X, and XI. Although chordoma was initially suspected, the atypical imaging features prompted further evaluation. FDG-PET revealed multifocal hypermetabolic lesions in the pancreas, spleen, pelvic lymph nodes, iliac/gluteal muscles, and subcutaneous tissue, with lytic bone involvement in the iliac crest and clivus. Laboratory tests showed mild leukopenia, elevated LDH (1270 U/L), and negative tumor markers (CA 19-9, CEA, β-hCG, CA-125). Cerebrospinal fluid (CSF) analysis and flow cytometry were negative for malignancy. A trans-sphenoidal biopsy was performed following tumor board discussion. Histopathological analysis confirmed DLBCL of non-germinal center phenotype RESULTS The disease was staged as Ann Arbor IV-A, with high-risk International Prognosis Index (IPI). Despite no CSF involvement, craniospinal radiotherapy, systemic chemotherapy (polatuzumab vedotin, rituximab, cyclophosphamide, doxorubicin) and intrathecal chemotherapy (cytarabine/methotrexate) were administered. At six months, the patient is clinically stable with neurologic improvement and complete metabolic response. CONCLUSION Secondary clival lymphoma is rare and may mimic other skull base tumors. Distinctive imaging features should raise suspicion. A multidisciplinary management is essential for timely diagnosis and treatment.

Identifying predictors for the diagnosis of acute invasive fungal rhinosinusitis: a comprehensive analysis.

Objective: To improve the understanding of the clinical manifestation of immunoglobulin G4-related disease (IgG4-RD) with neurological involvement. Methods: Patients presenting with neurological symptoms and biopsy-confirmed IgG4-RD were enrolled between March 2014 and March 2024 from the Department of Neurology of Xuanwu Hospital of Capital Medical University. Medical record data of all patients were retrospectively reviewed, including clinical manifestations, laboratory findings, radiological results, pathology, treatments, and outcomes. RD were enrolled between March Results: Nine patients (five males, four females; median age at onset: 63 years) were included in the study. Neurological manifestations consisted of pachymeningitis in six cases, peripheral nerve involvement in two, and brain parenchyma involvement in one. Four patients displayed isolated neurologic symptoms. The most common clinical manifestations were headache and cranial nerve palsy, each involving five cases. Magnetic resonance imaging showed thickening and enhancement of the dura mater in the six patients with pachymeningitis. Four of these cases involved the posterior cranial fossa, 3 presented with an inflammatory pseudotumor, and 2 involved the spinal cord. Four patients with pachymeningitis had normal serum IgG4 concentrations. Eight patients exhibited elevated serum C-reactive protein or erythrocyte sedimentation rates, with some also showing decreased complement C3 and C4 levels. Cerebrospinal fluid immunoglobulin was elevated in all nine cases. In all cases, histopathologic biopsy results showed extensive infiltration of lymphocytes and plasma cells, with the latter displaying IgG4+abnormalities. All patients received glucocorticoid therapy, with six also receiving immunosuppressants. All patients were followed up for a median of 30 months, with outcomes including two complete remissions, five partial remissions, one unchanged condition, and one death. Six patients experienced a relapse. Conclusions: Isolated hypertrophic pachymeningitis is the most common manifestation of IgG4-RD, often occurring in the absence of elevated serum IgG4 levels. Peripheral nerve and brain parenchyma involvement can also be seen. Clinical manifestations are non-specific, and histopathologic biopsy is frequently required for diagnosis. Although the disease responds well to hormone treatment, recurrence is common. Early combined immunosuppressive therapy can improve prognosis.

ABSTRACTWernicke's encephalopathy (WE) is an acute neurological disorder that develops due to thiamine (vitamin B1) deficiency. While it is common in chronic alcoholism, WE can also manifest due to other conditions, including extreme fasting. This report presents a unique case of WE occurring after a 40‐day water‐only fast, emphasizing the importance of recognizing nonalcoholic causes of WE. A 36‐year‐old male presented with diplopia, gait instability, and confusion following a 40‐day water‐only fast. Neurological examination revealed bilateral sixth cranial nerve palsy, ataxic gait, and confusion. Magnetic resonance imaging demonstrated bilateral medial thalami and periaqueductal hyperintensities, consistent with WE. He received high‐dose intravenous thiamine and electrolyte correction, resulting in substantial improvement. This case underscores the potential occurrence of WE in healthy individuals following extreme fasting. Early identification and treatment with thiamine are essential to prevent irreversible neurological damage. Clinicians should be cautious of WE in at‐risk patients without a history of alcohol use.

Adenomas of the pituitary gland, predominantly prolactinomas, can exhibit aggressive behavior. Aggressive prolactinomas are characterized by radiographic invasion, rapid growth, clinically significant progression despite standard therapies, and recurrence after surgery or radiotherapy. Pituitary carcinoma is rare (0.1-0.2% of pituitary tumors) [1, 2]. Case Presentation: In 2005, a 50-year-old man presented with bitemporal hemianopsia and severe asthenia due to a large pituitary tumor. Hormonal tests revealed hyperprolactinemia and panhypopituitarism; he received hormonal replacement and dopamine agonists (DA) therapy with a reduction in prolactin levels. Ten years later, he experienced tumor regrowth consistent with pituitary apoplexy and VI cranial nerve palsy. MRI showed a macroadenoma with suprasellar extension and compression of the optic structures. The patient underwent transsphenoidal surgery in view of the partially resistant disease. Histopathology showed a pituitary macroadenoma, and immunohistochemistry showed a high mitotic index (Ki-67 80%). In 2016, the patient developed a partial deficit of the left sixth cranial nerve. He underwent a new surgery but with incomplete resection. In view of the aggressive and resistant nature of the disease, he received radiotherapy. In 2020, prolactin levels began to increase again. MRI showed an occipital- temporal lesion. Subsequently, he underwent radiotherapy and started chemotherapy with temozolomide, resulting in the normalization of prolactin levels in the absence of DA therapy. The patient is currently in remission, with no evidence of tumor recurrence. Conclusion: It was found that 15% of prolactinomas are resistant to DAs, and resistance to DA may signal malignant transformation. Therefore, multimodality therapy and molecular analysis are critical for aggressive prolactinomas and pituitary carcinoma.

BackgroundThe endoscopic endonasal approach (EEA) is the mainstay of resection for lesions in the retroinfundibular area and the prepontine and interpeduncular cisterns. Owing to the anatomical barrier of structures such as the pituitary gland (PG)/pituitary stalk (PS), dorsum sellae (DS) and posterior clinoid process (PCPs), sufficient tumour resection often requires displacement of the pituitary gland and varying degrees of bony resection.MethodsWe retrospectively studied the clinical data of 23 patients, from June 2016 to February 2023,who underwent endoscopic endonasal intradural pituitary gland transposition (PGT) as well as dorsectomy and posterior clinoidectomy for the treatment of lesions involving the retroinfundibular area, prepontine cistern and interpeduncular cisterns. Outcomes, including postoperative complications and the extent of tumour resection (EOR), were evaluated.ResultsAmong the 23 patients with tumours, 16 had craniopharyngiomas, 3 had germ cell tumours, 2 had epidermoid cysts, and 2 had gliomas. Fifteen patients underwent unilateral PGT and ipsilateral dorsectomy, and 8 patients underwent ipsilateral posterior clinoidectomy. Ten patients with visual impairment improved, and none of the patients experienced cranial nerve palsy postoperatively. Fourteen patients developed hypopituitarism, and 8 patients experienced diabetes insipidus (DI) postoperatively, 6 and 4 of theses patients recovered after 2–4 weeks of replacement therapy. Twelve patients with intraoperative high-flow CSF leakage underwent an average of 7 days of early postoperative lumbar drain (LD). Among them, 4 patients developed an infection, which was cured by 10 days of antibiotic treatment combined with LD. None of the patients experienced constant CSF leakage at the discharge. Gross total resection (GTR) was achieved in 19 tumour patients, and near-total resection (NTR) was achieved in 4 patients. The average follow-up period was 26 months, and magnetic resonance imaging (MRI) revealed no tumour recurrence in 22 patients.ConclusionTumours of the retroinfundibular area, prepontine and interpeduncular cisterns can be safely removed via the PGT technique. The intradural PGT technique combined with flexible dorsectomy and posterior clinoidectomy has obvious advantages, including less intraoperative bleeding, more effective pituitary transposition, and good preservation of pituitary function. Owing to the complexity of these regions, this technique should be performed by experienced endoneurosurgeons.