Parasellar Masses Research Articles

OTHR-17 MANAGEMENT AND OUTCOMES OF SELLAR, SUPRASELLAR, AND PARASELLAR MASSES IN LOW- AND MIDDLE-INCOME COUNTRIES: A SCOPING REVIEW AND PROPORTIONAL META-ANALYSIS OF 6584 MASSES

Abstract OBJECTIVE To aggregate data on treatment modalities, management approaches, and clinical outcomes of sellar, suprasellar, and parasellar masses in LMICs. METHODS We conducted a scoping review as per the Arksey and O’Malley framework. MEDLINE, Embase, Global Index Medicus, and African Journals Online were searched and included articles between 2000 and 2021 screened against predefined eligibility criteria. Pooled statistics were calculated using measures of central tendency and spread. A proportional meta-analysis was conducted to pool the mortality rates. RESULTS Of the 3526 articles generated by the search strategy, 173 articles were included. The mean age was 35.5 ± 15 years, and most were females (56.47%). Sellar masses predominated (85%; 95% CI = 93.16–118.58), and the most commonly used neuroimaging modality to diagnose these masses was an MRI (65.31%). Surgical resection was mostly utilised with endoscopic surgery (78%; 95% CI = 17.29–154.96) predominating over microsurgery (22%; 95% CI = 11.51–47.73). The transsphenoidal approach was mostly used for both endoscopic surgery and microsurgery (92.13% vs 93.21%), and the extent of resection was gross total resection in most cases (n = 3611). Non-surgical management included hormonal therapies (n = 2080), chemotherapy (n = 96 patients), and radiosurgery (n = 357). New onset diabetes insipidus (34.27%), followed by postoperative infection (27.95%), were the most commonly reported postoperative complications. The pooled overall mortality rate was 8.1% (95% CI: 0.031–0.146). CONCLUSION Although MRIs are considered to be the gold standard means of diagnosis for these masses, their use in LMICs is less reported. Despite new minimally invasive treatment options, endoscopic surgery is commonly used in LMICs. These translates to the fact that more effort is required in the effective care of patients with these masses in LMICs.

ODP333 Mucosal-Associated Lymphoid Tissue Lymphoma: a Rare Condition in the Differential Diagnosis of a Parasellar Mass

Abstract The differential diagnosis for sellar and parasellar masses is broad and includes pituitary tumors, inflammatory lesions, meningioma, and lymphoma. In rare cases, the latter can manifest as extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT)-subtype. We report a case of MALT-lymphoma presenting as a parasellar mass. A 68-year-old woman presented with several months of diplopia, cognitive slowing, and progressive balance issues. Brain MRI revealed a 4.6×2.3×1. 0 cm dural skull-based lesion extending from the left tentorium cerebelli to the left cavernous sinus and sella with mass effect on the optic chiasm and pituitary gland. Hormonal assessment revealed elevated prolactin at 93 ng/mL (NR 2.8-29.2) thought to be due to stalk effect. There were no abnormalities in other axes. CSF analysis demonstrated elevated protein (211 mg/dL, NR 15-45) and was negative for malignant cells. Due to the degree of cavernous sinus involvement, the mass was deemed surgically unresectable. Her PCP started dexamethasone 10mg daily for her neurologic symptoms, resulting in subsequent symptomatic improvement, reduction in mass size, and normalization of prolactin. However, she experienced weight gain, glucose intolerance, and fatigue, so dexamethasone was tapered and stopped after a 5-month course. Nine months later, she re-presented with symptoms of a sixth cranial nerve palsy. MRI demonstrated interval increase in mass size, protrusion into the left sella, and possible upward displacement of the pituitary. No pituitary hormone deficiencies were noted. Tumor biopsy and debulking revealed MALT-lymphoma. She received external beam radiation (200 cGy/fraction for 12 fractions) with improvement in symptoms and size of the mass. A PET-CT showed no evidence of other FDG-avid lesions. Follow-up MRI showed resolution of the mass with only minimal thickening along the left cavernous sinus. She continues to follow with Endocrinology post-radiation therapy for hormonal monitoring. Her pituitary axes have remained intact for 7 years. Steroid-responsive sellar and parasellar masses often invoke associations with inflammatory conditions such as sarcoidosis and idiopathic hypertrophic pachymeningitis. Lymphoma, and in particular MALT-lymphoma, also need to be considered in the differential diagnosis for these lesions. MALT-lymphomas of the central nervous system (CNS) tend to occur in women and arise from the dura. In one retrospective analysis, about 50% of cases occurred as primary lymphoma in the CNS while the remaining had systemic disease. Ten out of 13 subjects (77%) in a case series of primary CNS MALT-lymphoma had a complete response to surgery, chemotherapy, and/or radiation therapy. In a separate retrospective analysis, 3 out of 70 subjects (4.3%) experienced a recurrence over a median follow-up of 23 months after treatment. Given the importance of radiation therapy to the management of these tumors, Endocrinologic follow-up is essential given the increased risk of hypopituitarism after intracranial radiation. Presentation: No date and time listed

PMON47 Fluid restriction reduces hyponatremia and hospital readmission rates following pituitary surgery

Abstract Rationale: Hyponatremia occurs in approximately 20% of patients after transsphenoidal pituitary surgery (TSS). Symptomatic delayed hyponatremia from SIADH is a major cause of morbidity and hospital readmission. Prophylactic fluid restriction (FR) protocols starting 2-5 days after surgery may potentially reduce rates of symptomatic hyponatremia and readmissions. Methods Patients who underwent TSS for sellar and parasellar masses at a tertiary referral center were discharged with a one-liter fluid restriction protocol. Serum sodium levels were measured on post-operative day (POD) 7 with telephone follow-up care. Rates of hyponatremia and readmissions were compared to a cohort of 316 post-operative patients treated prior to the protocol. Numerical variables were summarized as mean ± SD and significance testing calculated by Chi-square and t-test. Results 105 patients were enrolled on the FR protocol upon discharge. Twelve patients were excluded as they had diabetes insipidus or prolonged hospitalization beyond POD 7. Ninety-three patients were included in the analysis, of whom 74.3% had pituitary adenomas, 5.4% Rathke's Cleft cysts, 8.6% meningiomas, 5.4% apoplexy, 2.2% craniopharyngiomas, and 4.3% other masses. Hyponatremia occurred in 13/93 (14%) patients. Mean POD 7 sodium was 137.9 mmol/L across the entire cohort. Two patients (2.1%) were readmitted for hyponatremia, while 3 were re-admitted for other causes. 88/93 (94.6%) of patients complied with the FR protocol. Of the 5 non-compliant patients, 2 developed hyponatremias (40%) compared to 3/88 (3.4%) in those who complied (p=0.008). Mean POD7 sodium was 138 (+/-4.5) mmol/L in those that complied and 135 (+/- 4.7) mmol/L in those who did not. Overall readmission rate for those with postoperative hyponatremia was 23% compared to 2.5% for those with normal sodium levels (p=0.0023). 15.4% of patients with hyponatremia were re-admitted for hyponatremia treatment, compared to 0/80 (0%) of those who did not develop post-operative hyponatremia (p=0.0004). Age and BMI did not impact hyponatremia rates. In 316 patients treated in 2012-2018 prior to the FR protocol, 78 (24.7%) developed delayed hyponatremia with 6% readmitted for hyponatremia. Thirty nine percent of patients with delayed hyponatremia were re-admitted, compared to 7.6% for those without hyponatremia. Compared to patients not on FR, patients on the FR protocol had 50% reduced risk of hyponatremia (OR=0.49 (95% CI 0.26-0.94, p=0.03), and a 3-fold reduced risk of overall readmissions (OR=0.31; 95% CI 0.12-0.81, p=0.0157) and readmission for hyponatremia (OR= 0.34;95% CI 0.08-1.5, p=0.16). A post-operative CSF leak or use of a lumbar drain were associated with an increased readmission rate in the historical cohort. Conclusion Instituting a one-liter daily FR protocol in patients after TSS results in significantly reduced rates of hyponatremia, overall readmissions, and readmission for symptomatic hyponatremia. A FR protocol should become routine practice in the post-operative care of patients undergoing pituitary surgery. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Management and outcomes of sellar, suprasellar and parasellar masses in low- and middle-income countries: a scoping review protocol

Abstract Sellar, suprasellar or parasellar masses refer to space-occupying lesions that arise from the area surrounding the pituitary gland and many other vital structures, which can impact quality of life if damaged. Therefore, optimal management by a multidisciplinary team, which includes neurosurgeons, would be required to ensure that patients receive timely intervention to prevent long-term co-morbidities. The landscape of management of these masses in high-income countries are well described in the literature, however, there is a lack of clarity in the counterpart low- and middle-income countries, thus necessitating an evaluation of the literature. This protocol outlines how we will conduct our scoping review on the topic of interest. MEDLINE, Embase, Global Index Medicus and African Journals Online will be searched from year 2000 to date in order to identify the relevant studies. Patients with a sellar, suprasellar or parasellar masses managed in an LMIC will be included. Surgical, medical and conservative management of the relevant masses will be considered. Articles in English and French will be included. Primary outcome will describe the management of sellar, suprasellar, or parasellar masses in LMICs. Secondary outcomes will include describing the epidemiology, presentation and outcomes of patients with sellar, suprasellar or parasellar masses. This scoping review will be the first to evaluate the current landscape of the management and outcomes of sellar, suprasellar and parasellar masses in LMICs, highlighting important themes that may be used to guide further research as well as health system strengthening efforts by policymakers, governments and stakeholders.

Retrospective Review of Surgical Site Infections after Endoscopic Endonasal Sellar and Parasellar Surgery: Multicenter Quality Data from the North American Skull Base Society.

Introduction Transnasal access to the anterior skull base provides a minimally invasive approach for sellar and parasellar masses compared with its open counterparts. The unique microbiome of the sinonasal mucosa provides distinct challenges not encountered with other cranial approaches. The use of antibiotics in these cases has not been standardized, and data remain scarce regarding infectious outcomes. Methods We conducted a multicenter retrospective analysis of shared quality data points for the endoscopic endonasal approach (EEA) for pituitary adenomas, along with other sellar and parasellar region masses that were included by participating institutions. Patient and operative characteristics, perioperative and postoperative antibiotic regimens and their durations, intraoperative and postoperative cerebrospinal fluid leak, and onset of postoperative meningitis and sinusitis were compared. Results Fifteen institutions participated and provided 6 consecutive months' worth of case data. Five hundred ninety-three cases were included in the study, of which 564 were pituitary adenomectomies. The incidences of postoperative meningitis and sinusitis were low (0.67 and 2.87% for all pathologies, respectively; 0.35% meningitis for pituitary adenomas) and did not correlate with any specific antibiotic regimen. Immunocompromised status posed an increased odds of meningitis in pituitary adenomectomies (28.6, 95% confidence interval [1.72-474.4]). Conclusions The results show no clear benefit to postoperative antimicrobial use in EEA, with further larger studies needed.

RARE-04. Hypothalamic syndrome – severe sequelae due to different sellar and parasellar masses

Abstract Hypothalamic syndrome is a rare disorder caused by disease- and/or treatment-related injury to the hypothalamus, most commonly associated with rare, noncancerous parasellar masses such as craniopharyngioma, germ cell tumours, gliomas, cysts of Rathke’s pouch and Langerhans cell histiocytosis as well as genetic neurodevelopmental syndromes such as Prader-Willi syndrome and septo-optic dysplasia. Hypothalamic syndrome is characterized by intractable weight gain associated with severe morbid obesity and memory impairment, attention deficit, reduced impulse control as well as increased risk of cardiovascular and metabolic disorders. Currently, there is no cure for this condition. Treatments used for general obesity such as surgery, medication and counselling are often tried in hypothalamic syndrome, but are mostly ineffective, and there are no medications specifically approved for hypothalamic syndrome. The most important aspects of presentation and outcome of hypothalamic syndrome due to different neuro oncological diseases, its risk factors and an overview of currently available therapeutic interventions aiming to decrease and ameliorate the consequences of hypothalamic dysfunction will be presented. Furthermore, novel aspects and perspectives for future research will be discussed.

Cavernous haemangioma of cavernous sinus causing diagnostic dilemma: a case report with review of literature

BackgroundCavernous haemangioma of the cavernous sinus is an uncommon vascular malformation. It is often confused with other parasellar masses like schwannomas and meningiomas due to overlap in imaging appearance. It is important to pre-operatively diagnose this condition as it is associated with severe intra-operative bleeding.Case presentationHere, we report a case of an octogenarian female who presented with left sided progressive ptosis and diminution of vision for one year. Cross-sectional imaging includes computed tomography and magnetic resonance imaging which were not conclusive of cavernous sinus haemangioma. Digital subtraction angiography was done which showed a vascular blush. After corroborating the findings of these imaging investigations, a diagnosis of cavernous sinus haemangioma was concluded. Patient underwent surgery which showed a hypervascular mass. Histopathology was consistent with the imaging diagnosis. Patient was discharged in good stable condition and doing well and is on follow-up in Neurosurgery Out-Patient Department.ConclusionsThe cavernous sinus Haemangiomas are uncommon benign vascular masses. They pose a diagnostic challenge when seen in the parasellar region as the imaging findings of a haemangioma, meningioma and schwannoma in this location can have a significant overlap in the imaging findings. Cross-sectional imaging, digital subtraction angiography and nuclear imaging help in pre-operative diagnosis which is a crucial as the surgery is associated with significant blood loss.

Hypothalamic syndrome.

Hypothalamic syndrome (HS) is a rare disorder caused by disease-related and/or treatment-related injury to the hypothalamus, most commonly associated with rare, non-cancerous parasellar masses, such as craniopharyngiomas, germ cell tumours, gliomas, cysts of Rathke's pouch and Langerhans cell histiocytosis, as well as with genetic neurodevelopmental syndromes, such as Prader-Willi syndrome and septo-optic dysplasia. HS is characterized by intractable weight gain associated with severe morbid obesity, multiple endocrine abnormalities and memory impairment, attention deficit and reduced impulse control as well as increased risk of cardiovascular and metabolic disorders. Currently, there is no cure for this condition but treatments for general obesity are often used in patients with HS, including surgery, medication and counselling. However, these are mostly ineffective and no medications that are specifically approved for the treatment of HS are available. Specific challenges in HS are because the syndrome represents an adverse effect of different diseases, and that diagnostic criteria, aetiology, pathogenesis and management of HS are not completely defined.

Visual deterioration after endonasal endoscopic skull base surgery: causes, treatments, and outcomes.

Visual deterioration after endoscopic endonasal transsphenoidal surgery (EETS) for sellar and parasellar masses is a rare but serious complication caused by either compressive or ischemic mechanisms. Timely diagnosis and intervention may restore vision if instituted appropriately. The associated risk factors and their relation to the success of intervention are not well understood. The authors examined a series of 1200 consecutive EETS cases performed by the senior author at Weill Cornell/NewYork-Presbyterian Hospital from 2010 to 2020. Cases with postoperative visual deterioration were identified. Pre- and postoperative clinical data, mechanism of visual decline, latency to intervention, and long-term visual outcome were retrospectively collected and analyzed with appropriate statistical methods. Twenty-one patients (1.75%) complained of early postoperative visual deterioration. The most common pathology associated with postoperative visual loss was craniopharyngioma (7.69%), followed by meningioma (5.43%) and then pituitary adenoma (1.94%). Timely intervention restored vision in 81% of patients for a 0.33% rate of permanent visual deterioration. Average time to visual deterioration was 28.8 hours, and over 70% of patients experienced vision loss within the first 13 hours. Compressive etiology (n = 11), consisting of either hematoma (n = 8) or graft displacement (n = 3), occurred 7.3 hours and 70.3 hours after surgery, respectively, and was more common in adenomas. Acute postoperative visual deterioration was more common in firm closures (4.78%) compared with soft closures (1.03%; p = 0.0006). Ischemic etiology (n = 10) occurred 10.3 hours after surgery and was more common with craniopharyngiomas and meningiomas (p = 0.08). Sixteen patients (76.2%) underwent early reoperation to explore and decompress the optic apparatus. Vision was restored to baseline after reoperation in all 11 compressive cases, whereas 6/10 ischemic cases improved with supplemental oxygen and hypervolemic hypertensive therapy (p = 0.02). Fluid expansion from 8 to 16 hours (p = 0.034) and systolic blood pressure elevation from 32 to 48 hours (p = 0.05) after surgery were significantly higher in those ischemic patients who recovered some vision compared with those with persistent visual deficits. Visual deterioration after EETS is a rare event but can be effectively treated if acted upon appropriately and in a timely fashion. Compressive etiology is reversible with early reoperation. Ischemic etiology can be successfully treated in roughly half of cases with supplemental oxygen and hypertensive hypervolemic therapy but may result in permanent visual deterioration if not instituted appropriately or if delayed with unnecessary exploratory surgery.

Management and outcomes of sellar, suprasellar, and parasellar masses in low-and middle- income countries: a scoping review

Management and outcomes of sellar, suprasellar, and parasellar masses in low-and middle- income countries: a scoping review

Sellar, suprasellar, and parasellar masses: Imaging features and neurosurgical approaches.

The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.

Imaging Spectrum of Sellar and Parasellar Masses in a Paediatric Population: a Pictorial Essay

Imaging Spectrum of Sellar and Parasellar Masses in a Paediatric Population: a Pictorial Essay

Role of MRI in the evaluation of Sellar and Parasellar masses

Introduction: Sellar and parasellar/juxtasellar regions are sophisticated areas of the brain, and varied types of tumors can present in this area. Preoperative non-invasive diagnosis with magnetic resonance imaging (MRI) is essential for treatment planning. Aim: The aim of this study is to characterize MRI features of the sellar and juxtasellar tumors and to correlate MRI diagnosis with histopathological diagnosis in order to evaluate the efficiency of MRI. Materials and Methods: Patients with sellar and juxtasellar lesions who were operated during September 2017–May 2020 and the pathological reports were compared with the MRI findings retrospectively. Results: 100 patients in total were enrolled for this study. Results were analysed and discussed. Conclusions: The present study revealed a strong correlation between MRI and histopathological diagnosis for sellar and juxtasellar tumors. MRI is the modality of choice to distinguish and describe sellar- suprasellar lesions.

Effect of Omega-3 Supplementation in Patients With Smell Dysfunction Following Endoscopic Sellar and Parasellar Tumor Resection: A Multicenter Prospective Randomized Controlled Trial.

Endoscopic endonasal approaches pose the potential risk of olfactory loss. Loss of olfaction and potentially taste can be permanent and greatly affect patients' quality of life. Treatments for olfactory loss have had limited success. Omega-3 supplementation may be a therapeutic option with its effect on wound healing and nerve regeneration. To evaluate the impact on olfaction in patients treated with omega-3 supplementation following endoscopic skull base tumor resection. In this multi-institutional, prospective, randomized controlled trial, 110 patients with sellar or parasellar tumors undergoing endoscopic resection were randomized to nasal saline irrigations or nasal saline irrigations plus omega-3 supplementation. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and at 6 wk, 3 mo, and 6 mo postoperatively. Eighty-seven patients completed all 6 mo of follow-up (41 control arm, 46 omega-3 arm). At 6 wk postoperatively, 25% of patients in both groups experienced a clinically significant loss in olfaction. At 3 and 6 mo, patients receiving omega-3 demonstrated significantly less persistent olfactory loss compared to patients without supplementation (P=.02 and P=.01, respectively). After controlling for multiple confounding variables, omega-3 supplementation was found to be protective against olfactory loss (odds ratio [OR] 0.05, 95% CI 0.003-0.81, P=.03). Tumor functionality was a significant independent predictor for olfactory loss (OR 32.7, 95% CI 1.15-929.5, P=.04). Omega-3 supplementation appears to be protective for the olfactory system during the healing period in patients who undergo endoscopic resection of sellar and parasellar masses.

SUN-434 Simultaneously Occurring Suprasellar Tumor and Meningitis: A Rare Cause of Hypopituitarism

Background: The most common cause of hypopituitarism is pituitary adenoma. In recent years there is increased reporting of rare causes of hypopituitarism acquired in adulthood, such as other sellar and parasellar masses, brain damage, vascular lesions, infiltrative/immunological/inflammatory diseases and infectious diseases. We report an unusual case of hypopituitarism associated with simultaneously occurring suprasellar tumor and meningitis. Clinical case: A 45-year-old man was brought to the Emergency Department after being found collapsed at his home with a reduced level of consciousness. About 1 week ago, the patient was complaint headache, nausea and vomiting. He had no significant medical history. His initial assessment showed a blood pressure of 130/70 mmHg, heart rate 133/min, and body temperature 38.5 ºC. Initial laboratory finding revealed serum sodium level of 149 mmol/L (135-150), potassium level of 4.3 mmol/L (3.5-5.5), serum osmolality 292 mOsm/Kg (275-295) and urine osmolality 504 mOsm/Kg (400-800). His random cortisol level was 31.8 ug/dl, TSH 0.568 uIu/ml (0.55-4.78), and free T4 10.75 pmol/L (11.5-22.7). From clinical examination and initial investigations, he was diagnosed as having meningitis or encephalitis and was promptly commenced on empirical i.v. antibiotics. The magnetic resonance imaging (MRI) of the brain revealed diffuse leptomeningeal enhancement in both cerebral hemisphere and 1.8*1.5*1.1cm sized, oval-shaped mass in suprasellar portion, which combined peripheral edema. Examination of the cerebrospinal fluid (CSF) following lumbar puncture confirmed meningitis, antibiotics and antiviral agent were continued. After 2 weeks, he suddenly underwent hypotension and polyuria, despite inflammatory markers of blood were improved. Laboratory finding showed serum osmolality 337 mOsm/Kg, urine osmolality 271 mOsm/Kg, serum sodium 153 mmol/L, random cortisol 1.3 ug/dl, and free T4 5.19 uIu/ml. When coupled with the initial results of the brain imaging, this result helped to confirm a hypopituitarism associated with suprasellar tumor and meningitis. The patient's clinical status promptly improved with intravenous hydrocortisone and desmopressin. After that, levothyroxine supplement was started. He had good response to hormone replacement. Conclusion: Hypopituitarism may develop rapidly or slowly depending on the underlying etiology and may involve one, multiple, or all of the pituitary hormones. The clinical presentations of hypopituitarism are usually nonspecific and the recognition of these patients remains the challenge. We emphasize the importance of careful clinical assessment and focused investigations, including cranial imaging and pituitary hormone profiling to establish the underlying diagnosis.

MON-432 Symptomatic Pituitary Metastases: A Report of 16 Cases

Introduction: Pituitary Metastases (MTS) are infrequently seen in clinical practice. The incidence ranges from 0.14 to 28%. Breast and lung cancer are the primary sites that most frequently metastasize to sellar region, between the sixth and seventh decades of life. Most cases are diagnosed in patients with advanced malignant disease, however, in 20-30%, symptoms of pituitary involvement can precede the diagnosis of the primary tumor. Objectives: To evaluate symptoms at presentation, hormonal, radiological and histological findings, management and outcome of a series of patients with pituitary MTS. Patients and methods: medical records of 16 patients from eight Endocrine Centers were reviewed. Ten patients had histological confirmation of the pituitary MTS, 6 were not operated, being the diagnostic criteria the presence of sellar mass associated with diabetes insipidus (DI) and / or sudden-onset of neuro-ophthalmological symptoms in patients with confirmed primary neoplasia. Results: The median age was 54 years (range 35-70), 9 women (56.2%). The sites of the primary tumor were: 7 lung (44%), 5 breast (32%), 1 follicular thyroid carcinoma (6%), 1 Hodgkin lymphoma (6%), 1 poorly differentiated carcinoma (6%), and 1 clear cell renal carcinoma (6%). The median time between the diagnosis of the primary neoplasm and the occurrence of the pituitary MTS was 12 months (range: 3-120). In 9 patients (56.2%), the diagnosis of the primary neoplasm was made after the finding of the symptomatic sellar mass. DI was found in 14 patients (87.5%), adenohypophyseal deficit in 12 (75%), visual disorders in 10 (62.5 %), headache in 6 (37.5%) and cranial nerve deficits in 6 (37.5%). In 68.7% (11 patients), other MTS were detected. Fifteen patients were evaluated by MRI and one by CT: 13 (81.3%) harbored supra / parasellar masses, and the remaining 3 had lesions limited to the pituitary gland, with stalk thickening and lack of spontaneous neurohypophysis hyperintensity in 2 of them. In all cases diffuse gadolinium uptake was present. Fourteen patients died (87.5%), with a median survival time of 6,5 months (range: 1-36); the remaining 2 are still alive with a follow-up period of 4 and 12 months respectively. Conclusions: In this series of 16 patients with pituitary MTS, the most frequent primary neoplasms were lung and breast. Median age was lower than in published series. DI was the most common condition at presentation, followed by hypopituitarism and visual disorders. The short survival was related to the extent of the disease at the time of diagnosis. In more than half of the cases the diagnosis of primary neoplasia was made through the symptomatic pituitary mass. In the presence of a pituitary lesion with diffuse gadolinium uptake, associated with DI and / or acute visual deficit, pituitary MTS should be suspected even in patients without a history of oncological disease.

Current best practice in the management of patients after pituitary surgery.

Sellar and parasellar masses are a common finding, and most of them are treated surgically via transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.

Spontaneous retroclival hematoma in pituitary apoplexy: case series

Pituitary apoplexy is a rare and potentially life-threatening disorder that is most commonly characterized by a combination of sudden headache, visual disturbance, and hypothalamic/hormonal dysfunction. In many cases, there is hemorrhagic infarction of an underlying pituitary adenoma. The resulting clinical symptoms are due to compression of the remaining pituitary, cavernous sinuses, or cranial nerves. However, there are only 2 case reports in the literature describing spontaneous retroclival expansion of hemorrhage secondary to pituitary apoplexy. Ten cases of this entity with a review of the literature are presented here. This is a single-institution retrospective review of 2598 patients with sellar and parasellar masses during the 10-year period between 1999 and 2009. The pituitary and brain MRI and MRI studies were reviewed by 2 neuroradiologists for evidence of apoplexy, with particular attention given to retroclival extension. Eighteen patients (13 men and 5 women; mean age 54 years) were identified with presenting symptoms of sudden onset of headache and ophthalmoplegia, and laboratory findings consistent with pituitary apoplexy. Ten of these patients (8 men and 2 women; mean age 55 years) had imaging findings consistent with retroclival hematoma. Retroclival hemorrhage was seen in the majority of cases of pituitary apoplexy (56%), suggesting that it is more common than previously thought.

Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients

The cavernous sinus and surrounding regions-specifically the Meckel cave, posterior sector of the cavernous sinus itself, and the upper part of the petroclival region-are the location of a large variety of lesions that require individual consideration regarding treatment strategy. These regions may be reached for biopsy by a percutaneous needle inserted through the foramen ovale. The aim of this retrospective study was to evaluate the diagnostic accuracy of percutaneous biopsy in a consecutive series of 50 patients referred for surgery between 1991 and 2010. Seven biopsies (14%) were unproductive and 43 (86%) were productive, among which 28 lesions subsequently underwent histopathological examination during a second (open) surgery. To evaluate the diagnostic accuracy of the procedure, results from surgery were compared with those from the biopsy. Sensitivity of the percutaneous biopsy was 0.83 (95% CI 0.52-0.98), specificity was 1 (95% CI 0.79-1), and κ coefficient was 0.81. Because of its valuable diagnostic accuracy, percutaneous biopsy of the cavernous sinus and surrounding regions should be performed in patients with parasellar masses when neuroimaging does not provide sufficient information of a histopathological nature. This procedure would enable patients to obtain the most appropriate therapy, such as resective surgery, corticosteroids, chemotherapy, radiotherapy, or radiosurgery.

Pituitary Magnetic Resonance Imaging for Sellar and Parasellar Masses: Ten-Year Experience in 2598 Patients

Sellar and parasellar masses present with overlapping clinical and radiological features ranging from asymptomatic incidental presentations and hormonal effects to compressive local mass effects. Pituitary masses are diagnosed with increased frequency with magnetic resonance imaging (MRI) advancements and availability, but indications and diagnostic outcomes of MRI screening for sellar lesions are not defined. Although pituitary adenomas are the most frequently encountered sellar mass lesions, other etiologies should be considered in the differential diagnosis of a sellar mass. The study was conducted at a tertiary pituitary center. This study was a retrospective review of 2598 subjects undergoing at least one pituitary MRI scan from 1999 to 2009. Prevalence and diagnosis of specific sellar and parasellar masses as screened by pituitary MRI. The most common indications for pituitary imaging, excluding known mass follow-up, were for evaluation of hyperprolactinemia or hypogonadism. A normal pituitary gland was reported in 47% of subjects undergoing pituitary MRI. The most common pituitary adenomas initially identified by MRI included prolactinoma (40%), nonfunctioning adenoma (37%), and GH adenoma (13%). Nonadenomatous sellar masses accounted for 18% of visible lesions, of which the most common were Rathke's cleft cyst (19%), craniopharyngioma (15%), and meningioma (15%). Metastases accounted for 5% of nonpituitary lesions and breast cancer was the most common primary source. Half of all pituitary MRI scans performed in a large patient population yielded no visible lesion. Nonadenomatous pituitary lesions should be considered in the diagnosis of sellar masses observed on MRI, and a high clinical suspicion is required to exclude the presence of a nonfunctioning pituitary adenoma.