Transsphenoidal Decompression Research Articles

Rathke’s cleft cyst: A case report

Abstract A Rathke cleft cyst (RCC) is a nonmalignant growth originating from Rathke’s pouch, which is the precursor to the anterior pituitary gland during early development. Most RCCs are asymptomatic and are typically discovered incidentally during computed tomography scans or magnetic resonance imaging (MRI). The progressive enlargement of the RCC is often symptomatic due to compression of the adjacent structures. The clinical presentations of the RCC are headache, visual disturbances, pituitary dysfunction causing hypogonadism, hyperprolactinemia, deficits of growth hormones, hypothyroidism, and diabetes insipidus. The conventional treatment of the symptomatic RCC is surgical excision through a transsphenoidal approach. Here, we are presenting a patient of Rathke’s cleft cyst presenting severe headache that was relieved after endoscopic transsphenoidal decompression of the cyst.

Pituitary Metastasis Masquerading as Pituitary Macroadenoma-from a Primary Follicular Thyroid Malignancy

Background: Metastasis to the pituitary is very rare. Thyroid carcinoma as a primary source of pituitary metastasis is uncommon. Pituitary metastasis is common in posterior pituitary. Metastasis can also occur to anterior pituitary with varied presentations. Case Description: A 47-year-old lady presented with galactorrhoea, ptosis, diminished vision of the right eye, and headache from 6 months. She had a pituitary macroadenoma with suprasellar, para-sellar and infrasellar extension on evaluation. She underwent initial transnasal transsphenoidal decompression followed by pteronial craniotomy with decompression of the residual tumour. The histopathology was metastatic tumor of sella. Further evaluation showed a thyroid nodule and bilateral lung nodules. With suspicion of a primary thyroid malignancy, total thyroidectomy was performed and biopsy report of the thyroid showed follicular carcinoma. Conclusion: Metastasis to the pituitary can be a rare presentation of thyroid cancer. It may masquerade a pituitary adenoma. Key-words: Sella, Pituitary metastases, Parasellar, Suprasellar, Diabetes Insipidus, Thyroid.

THU102 A Case Of Papillary Craniopharyngioma WHO Grade 1 Turned Into Abscess

Abstract Disclosure: R.J. Shah: None. J. Patel: None. P.A. Belany: None. Craniopharyngioma is a rare primary brain tumor located in the suprasellar region. Papillary craniopharyngiomas (PC) occur mostly in adults, between age 40-50. Despite surgery being the primary treatment, PCs have a high tendency for relapse. We present a case of PC WHO grade 1, positive for BRAF V600E mutation concerning for regrowth 10 months following surgical resection. A 45-year-old male presented to the emergency department with complaint of right orbital headaches, vision change and severe fatigue. CT head was normal and was discharged home. Headaches, fatigue, and vision change progressively worsened over the next week with new symptoms of erectile dysfunction, low libido, weight loss, polyuria, polydipsia and proximal muscle weakness developing. Morning labs showed FT4 0.5ng/dl, TSH 2.32uIU, cortisol 1.5ug/dl, ACTH 14 pg/mL, FSH 1.5mIU/mL, LH 0.2mIU/mL, total testosterone 6ng/dl, prolactin 17.5ng/mL, IGF-1 134 ng/mL and GH 0.2ng/dl concerning for panhypopituitarism. Chemistry panel was unremarkable. MRI pituitary confirmed sellar mass measuring 2.1x1.3x2.1cm compressing the optic chiasm. Evaluated by endocrinology, patient was started on hydrocortisone, levothyroxine and desmopressin and referred to neurosurgery. Following endoscopic endonasal approach (EEA), pathology showed PC WHO Grade 1 and molecular testing positive for BRAF V600E mutation. Two-month post-surgical MRI showed residual 8mm lesion. Active surveillance showed regrowth of sellar lesion to 1.8 cm with optic chiasm compression ten months following EEA. Repeat EEA was done with concern for relapse. Surprisingly, intraoperative purulent fluid draining from the sella was found and positive for Acinetobacter. Sellar abscess was drained and he received six weeks of intravenous antibiotics. Repeat MRI showed resolution of the entire sellar lesion, his vision normalized and continued to be on hormone replacement for panhypopituitarism. PCs are locally aggressive suprasellar lesions that can reach a large size prior to clinical symptoms developing. Around 90% of PC are positive for BRAF V600 mutation. Surgical resection and radiotherapy are the primary treatment, but newer studies have demonstrated tumor regression using BRAF targeted agents following relapse. Our case demonstrates a pituitary abscess (PA) found intraoperatively that was originally suspicious for tumor recurrence. PA is a rare and serious intrasellar infection associated with high mortality. It is difficult to diagnose preoperatively and can be misdiagnosed as recurrence or residual tissue. PA can be primary or secondary depending on etiology. PA associated with residual craniopharyngioma tissue is extremely rare and the exact pathophysiology is not well understood. If no evidence of sepsis or meningitis, treatment with transsphenoidal decompression and intravenous antibiotics has good clinical outcomes. Presentation: Thursday, June 15, 2023

MEN1 syndrome presents as Cushing’s disease with proximal lower limb weakness: A rare phenomenon

Abstract The typical presentation of MEN 1 syndrome in most cases is primary hyperparathyroidism. The manifestation of hypercortisolism due to a functional Pituitary microadenoma in an adult as the first presenting feature in MEN 1 is rare. This report of Cushing’s disease presenting as proximal muscle weakness due to an adrenocorticotrophic hormone (ACTH) producing pituitary microadenoma as the initial feature of multiple endocrine neoplasia type 1 is an unusual occurrence. The patient had presented with proximal muscle weakness of lower limbs along with abdominal striae and uncontrolled diabetes. On hematological and radiological evaluations, she was detected to have a pituitary microadenoma along with a parathyroid adenoma causing increased levels of ACTH, serum (S) cortisol, parathyroid hormone, and S calcium. The patient underwent a transsphenoidal decompression of the pituitary microadenoma using frameless neuronavigation. Within 2 weeks of surgery, the patient achieved normal levels of S cortisol. She is off medication for blood sugar control. At 6 months, follow-up, she is symptom-free.

Trend of Improvement in Visual Field Deficits after Transsphenoidal Endoscopic Surgery in Pituitary Tumour Patients: A Case Series

Abstract
 Introduction: Pituitary tumours account for approximately 15% of all brain tumours, and the growing tumours press against the optic chiasm, resulting in impairment of visual function manifested as visual field defects, decreased visual acuity, and decreased color vision . Compression of the optic chiasm by pituitary tumours generally results in selective loss of the temporal VFs, or bitemporal hemianopia, implying that the nasal retinal fibers are preferentially damaged. The reason for this preferential damage is not fully understood. Transsphenoidal surgery has been reported to safely reduce the pressure on the anterior visual pathway in most patients. Improvement in visual function may occur after transsphenoidal decompression of the chiasm. Because improvement in visual function may occur from a variety of proposed biologic processes.
 Case Series : The number of patients according to gender was 71% male (10 people) while 29% female (4 people). The age distribution was found mostly at the age of 40-50 years 36% (5 people). The most common clinical symptoms were field disturbances 85% (12 people). Patients complained of visual field disturbances for 1-2 years as many as 58% (7 people). Vision before surgery is /6 as much as 45% (4 people). Improvements in vision were found for 1 month postoperatively as much as 22% (2 people).
 Discussion : Compression of the optic chiasm by pituitary tumours generally results in selective loss of the temporal VFs, or bitemporal hemianopia, implying that the nasal retinal fibers are preferentially damaged. The minimally invasive transsphenoidal approach can be used effectively for 95% of pituitary tumours. Exceptions are those large tumours with significant temporal or anterior cranial fossa extension. In such circumstances, transcranial approaches are often more appropriate. Occasionally, combined transsphenoidal and transcranial approaches are used. Nevertheless, some surgeons extend the basic transsphenoidal exposure in order to remove some of these tumours and avoid a craniotomy . Potential mechanisms of axonal injury from a compressive lesion include direct disruption of conduction along the axon, impaired axoplasmic flow, demyelination with impaired signal conduction, and ischemia from compression or stretching of the blood supply of the chiasm by the tumour. An early fast phase of improvement is consistent with restoration of signal conduction along retinal ganglion cell axons after removal of a compressive lesion.In some individuals, we observed the rapid restoration of normal vision, which would be consistent with this hypothesis. In these individuals, a physiologic conduction block is presumably the main mechanism of injury.
 Conclusion: The pattern of improvement of visual function after decompression of the anterior visual pathways suggests three phases of improvement. Improvement in visual function may occur after transsphenoidal decompression of the chiasm. Because improvement in visual function may occur from a variety of proposed biologic processes, we sought to better define this potential for improvement.

Rathke’s Cleft Cyst Abscess—An Unusual Guest in The Sella

AbstractAbscess formation within a Rathke's cleft cyst (RCC) is extremely rare, particularly at a young age. We report the case of a young girl with abscess formation in RCC. A 21-year-old female presented with headache, vomiting, visual deterioration and features suggestive of hypopituitarism. She had bitemporal hemianopia with impairment of visual acuity. MRI revealed a cystic lesion in the sella with suprasellar extension and peripheral rim enhancement. On the basis of history and imaging, this was indistinguishable from more commonly encountered pituitary pathology. She underwent transsphenoidal decompression, which revealed yellowish purulent material that when cultured grew Staphylococcus epidermidis. Histological examination revealed numerous neutrophils and cyst wall lining with features characteristic of RCC. Postoperatively, she received antibiotics and replacement therapy for hypopituitarism. Three months later, she experienced deterioration in visual fields. Considering persistent disease, she underwent redo surgery which revealed similar findings. Postsurgery, pituitary MRI revealed an empty sella syndrome. Thereafter, follow-up for 1 year was stable with permanent diabetes insipidus and multiple pituitary hormone deficiency on supplementation. Although uncommon, we recommend considering RCC abscess as a differential diagnosis of a pituitary mass lesion, as predicting its presence can be difficult preoperatively. Persistent or recurrent disease is common in these cases, so timely diagnosis and adequate surgical drainage leads to lower morbidity and mortality.

Cerebral Infarction from Compression of the Internal Carotid Artery - A Rare Presentation of Pituitary Apoplexy

A 42-year-old female presented with sudden onset of headaches, left hemiplegia and bitemporal hemianopia. Radiological investigations revealed right anterior circulation infarction from mechanical obstruction of the right internal carotid artery by Pituitary Apoplexy. She underwent an urgent transsphenoidal decompression of the sella and had gradual resolution of symptoms.

Primary pituitary abscess: case report and suggested management algorithm

Purpose To describe a case of successful treatment of a patient with a rare primary pituitary abscess (PA) and propose a management algorithm. Summary of background data PA is an infrequent entity that can be life-threatening if not promptly diagnosed and treated. PAs can be primary or secondary, the latter in the presence of sellar anomalies, risk factors or a systemic or local infection. Symptoms are nonspecific, making clinical suspicion imperative. Magnetic Resonance Imaging (MRI) is the radiological tool of choice. Despite some characteristic radiographic signs, oftentimes the diagnosis is not suspected until surgical exploration. Treatment includes transsphenoidal decompression surgery with sampling of purulent material and abscess wall for appropriate microbiological staining and cultures (bacteria, mycobacteria and fungus) and prolonged antibiotic treatment. Pituitary hormonal deficiencies must be addressed as well. Methods and results We describe a case of a female patient who presented with headaches, anorexia and bitemporal hemianopsia. MRI revealed a peripherally enhancing sellar mass. Transsphenoidal surgery was performed, with intra-operative finding of purulent material. Cytology confirmed the presence of abundant leucocytes, but no pathogen was isolated. Patient completed three weeks of antibiotic therapy, with good clinical and radiological response. Headaches and visual deficits resolved. Hormonal substitution therapy was needed for six months after surgery. Conclusion This report highlights the importance of early recognition and treatment of PAs. The diagnosis is commonly very difficult before surgery, due to overlapping clinical, radiological and laboratorial findings with various other pathologies. Prompt management, with surgical decompression and appropriate antibiotic treatment, typically results in a low mortality rate and higher chance of full recovery of pituitary function. We propose a management algorithm for sellar masses suspected of being PAs.

Letter: Rongeurs, Neurosurgeons, and COVID-19: How Do We Protect Health Care Personnel During Neurosurgical Operations in the Midst of Aerosol-Generation From High-Speed Drills?

To the Editor: A neurosurgical team, including 10 neurosurgical nurses and 4 other hospital staff, were infected with the novel coronavirus by a neurosurgical patient who was admitted for an elective trans-sphenoidal operation.1,2 This neurosurgery patient initially had no symptoms or signs of respiratory tract infection before the operation and he only developed fever 3 d after the operation. He was subsequently diagnosed with coronavirus disease 2019 (COVID-19) 5 d after his trans-sphenoidal surgery. COVID-19 is an infectious disease that can be transmitted via droplets or aerosols to the respiratory tract. The viral load is high along the respiratory tract mucosa, including the nasal cavity, nasopharynx, and oropharynx.3 The viral ribonucleic acid (RNA) can be detected in the sputum, saliva, as well as in the serum.3-6 Medical staff is at high risk of exposure to the virus. It was reported that up to 29% of the initial cohort of the confirmed infected novel coronavirus cases were medical staff.7 Up to date, 3.8% of the confirmed COVID-19 cases were health care personnel (HCP) and 14.8% of their conditions were severe or critical.8 Overall, the mortality rate is around 4.1% (ranging from 0.25% to 8%).9 At the same time, the majority (up to 81%) of the cases have only mild symptoms.8 In fact, the majority of the patients had minimal or no symptoms during the incubation period in the first 3 to 6 d.5 Yet these asymptomatic or “presymptomatic” contacts were reported to be able to transmit the virus.10 Aerosol-generating medical procedures (AGMP) are any procedures performed on patients that can produce aerosols of various sizes.6 Hence, it is recommended that full personal protective equipment (PPE) should be worn during AGMP, such as intubation, for confirmed or suspected COVID-19. After intubation, the operating theater (OT) staff, including anesthetists, nurses, and other supporting staff, would usually take off some of their protective gear such as face shield, eye protection goggles, gloves, and long-sleeved waterproof gown. Some of them might also take off their masks with high filtration such as the particulate respirators. For neurosurgery, one might overlook the aerosol-generating property of powered instruments such as the use of high-speed drills.11 These are commonly used tools for craniotomy and other neurosurgical procedures. Bone scattering from temporal bone drilling can be up to 3.5 feet.12 Powered instruments had been shown to generate blood-containing aerosols with a concentration of hemoglobin detected in the ambient air.11 Viruses, including human immunodeficiency virus-1 (HIV-1), was demonstrated to be viable in the aerosols generated by surgical power instruments.13 For the neurosurgical operations requiring the dissection of the nasopharyngeal mucosa such as the trans-sphenoidal excision of pituitary tumor, the risk of “aerosolizing” the virus is very high with the use of high-speed drills in the nasal cavity. Nonurgent trans-sphenoidal operations should be suspended during this pandemic. For patients indicated for urgent or semiurgent trans-sphenoidal decompression, eye protection such as goggles should be worn by the neurosurgeons and the OT staff in view of the potential risks of transcorneal transmission. Nonpowered tools such as septum rongeur and Kerrison rongeur should be used to open the sphenoidal sinus and the sella floor instead of using high-speed drills. The Wuhan Blood Center and blood banks in the Hubei province started to test blood donations for SARS-CoV-2 RNA on February 10.4 As the novel coronaviral RNA can be present in the blood of confirmed or suspected asymptomatic contacts, these aerosols generated during neurosurgical procedures are potentially infectious. Hudson Brace and other hand drills can be used during emergency operations when the COVID-19 infection status was unknown and when the OT staff might not have full airborne PPE. For suspected COVID-19 cases requiring elective neurosurgical operations, COVID-19 infective status should be checked before the surgery. If the results are negative, then airborne precautions would not be required and the use of PPE can be rationalized. Overall, we recommend our fellow neurosurgeons and trainees to uphold the traditional craft of using hand drills and rongeur in order to minimize aerosol generation from the neurosurgical powered instruments during the COVID-19 pandemic. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Visual and Hormone Outcomes in Pituitary Apoplexy: Results of a Single Surgeon, Single Institution 15-Year Retrospective Review and Pooled Data Analysis.

Introduction Pituitary apoplexy commonly presents with visual and hormonal deficits. While traditionally regarded as an emergency, there have been increasing trends toward conservative management. Our institutional practice consists of early surgery; therefore, we reviewed our series evaluating vision outcomes, hormone function, and complications compared with the present literature. Methods We retrospectively reviewed our institution's medical records to identify pituitary apoplexy patients who were treated via the endoscopic endonasal approach by a single neurosurgeon (senior author). We recorded basic demographics, radiographic and operative features, and preoperative and postoperative vision and hormone status. Univariate and multivariate statistical analyses were performed. Pooled data analysis of visual outcomes in the current literature using Bayesian inference was performed. Results We identified 44 patients with histologically confirmed pituitary apoplexy treated by endoscopic transsphenoidal decompression; 77% were treated within 24 hours of presentation. Total 45% had cranial nerve (CN) palsy, 36% anopsia, and 20% had visual acuity deficits. Postoperatively, 100% of CN palsies improved, 81% of anopsias improved, and 66.7% of visual acuity deficits improved. Long-lasting panhypopituitarism (25%) and hypothyrodism (22%) were common. Cavernous sinus involvement predicted residual tumor ( p = 0.006). Pooled Bayesian inference showed 30% improvement in vision outcomes with surgical management compared with medical management with a number needed to treat of 3.3. Conclusion Early surgery for pituitary apoplexy was associated with excellent visual outcomes and the need for long-term hormone replacement is common. Cavernous sinus involvement is an independent predictor of residual tumor. Pooled statistical analysis favors aggressive surgical management of apoplexy for improved visual outcomes.

Surgical intervention for binocular blindness in pituitary apoplexy

PurposeBilateral blindness in patients with pituitary apoplexy is rare and infrequently studied. Visual outcomes after surgical decompression are unpredictable and predictors of favourable outcome not well defined. The purpose of this study was to determine whether vision can be salvaged in patients who present with bilateral blindness and what the time limit is before irreversible damage occurs. MethodsWe report a series of 5 patients who presented with bilateral blindness after pituitary apoplexy. Patients presented 1.5 to 15 days after losing complete vision. Four regained functional vision. All had endoscopic transsphenoidal decompression within 36 h of presentation. The 4 patients who had surgery within 7 days of ictus had recovery of functional vision. One patient presented late and was operated on day 15 post ictus, with no visual recovery. We review the literature regarding the incidence and outcome of bilateral blindness post-pituitary apoplexy and present the outcome of 52 patients from 1939 to 2011 who had surgical intervention. ResultsThere was an 80% recovery rate in the current series vs 0% from the historical comparison (p = 0.05). Surgical approach in the historical comparison was significant (p = 0.015). Median age and median time delay from ictus to surgery were not significant. ConclusionsFindings suggest that vision can be salvaged in patients who present with binocular blindness after pituitary apoplexy, especially if surgery is performed within the first 7 days of apoplexy. Even in delayed cases surgical decompression can be beneficial and should be performed to try and salvage functional vision.

Post-traumatic pituitary apoplexy: Case presentation and review of literature

Abstract Pituitary apoplexy is a dramatic condition that can occur spontaneously or triggered by various precipitating factors. Head trauma is a rare but well-recognized cause of apoplectics events. We present the case of an 81-year-old woman, with negative past medical history and under antiplatelet agents, who experienced an isolated VI cranial nerve palsy 24 h after a mild head trauma. Early brain CT revealed an unknown pituitary lesion without signs of intralesional bleeding. Only late brain MRI imaging revealed pituitary apoplexy together with a subarachnoid hemorrhage. After aggravation of neurological condition the patient, undergo endoscopic transsphenoidal decompression of cranial nerves with rapid deficits improvement. Our aim is to share our experience and to propose the first critical review of all cases of post-traumatic pituitary apoplexy described in literature. We also try to suggest some management advice for post traumatic pituitary apoplexy.

Case of an isolated oculomotor nerve damage caused by pituitary hemorrhage without cavernous sinus invasion

Abstract Introduction Pituitary apoplexy is a rare endocrine emergency. The term refers to an acute ischemia or hemorrhage into the gland, most often on the basis of preexisting adenoma. The clinical symptoms include a sudden headache, nausea, vomiting, ophthalmic symptoms and hormonal dysfunction. The most severe, life threatening complication of pituitary apoplexy is adrenal insufficiency. The patient may complain of vision disturbances preceded by headaches localized behind the eye. This reflects pressure toward optic nerve caused by expanding mass. When it invades cavernous sinus, it can reach and damage the 3rd, 4th, 5th and 6th cranial nerve. Focal brain ischemia may occur due to direct pressure on internal carotid artery or vasospasm in reaction to local factors. Aim To present an example of a clinical evaluation of the patient with an isolated oculomotor nerve damage and comorbidities like diabetes which alone may account for ischemic nerve damage. Case study We present a case report of a patient suffering from pituitary apoplexy without cavernous sinus involvement and an isolated oculomotor nerve damage. Results and discussion We revise literature on pathophysiology of the third cranial nerve damage in the setting of pituitary apoplexy and make an attempt to explain constellation of the symptoms in our patient. Conclusions Pituitary apoplexy should be taken into consideration during a sudden isolated oculomotor nerve palsy. Immediate transsphenoidal pituitary decompression is a potentially effective method of the treatment. In the setting of a little expanding lesion an oculomotor nerve function may be restored without any surgical intervention.

Evaluation of Consistency of Pituitary Macroadenoma Using Diffusion-weighted Imaging in Correlation With Surgical Findings

Objective: The consistency of pituitary macroadenomas can be a confounding factor during transnasal transsphenoidal decompression, often necessitating incomplete removal and need for a transcranial approach for complete tumor excision. Very few studies have evaluated preoperative tumor consistency in relation to imaging findings. Our objective was to determine whether conventional magnetic resonance images and diffusion-weighted (DW) imaging with apparent diffusion coefficient (ADC) maps are predictive of the consistency of pituitary macroadenomas. Methods: A retrospective study of 31 patients who had undergone surgery for pituitary macroadenoma in our hospital. Preoperative magnetic resonance images were reviewed and regions of interest were drawn on the macroadenoma and normal white matter on DW images independently by 2 neuroradiologists. Consistency of macroadenomas was determined from the surgical records and was classified into soft, intermediate, or hard. Mean ADC values, signal intensity ratio of tumor to white matter within regions of interest on conventional and DW images, and degree of enhancement were compared with tumor consistency using analysis of variance. Results: The mean ADC values in the soft group was 0.754×10−3 mm2/s, in the intermediate group was 0.963×10−3 mm2/s, and in the hard group was 1.312×10−3 mm/s. Statistical analysis revealed a significant correlation between consistency and ADC values (P<0.004). There was no significant association between tumor consistency and signal intensity or degree of contrast enhancement. Conclusions: The findings in this study suggest that DW images with ADC maps are useful for preoperative prediction of consistency of pituitary macroadenomas.

Skull-base Ewing sarcoma with multifocal extracranial metastases

Intracranial occurrence of Ewing sarcoma (ES) is unusual, with a skull-base location being anecdotal. We report a 29-year-old man who presented with rapidly progressive ophthalmoplegia, and was found to be harboring an infiltrative lesion involving the sphenoid sinus, sella, and clivus. He underwent trans-sphenoidal decompression of the lesion which was histologically suggestive of ES. He developed paraparesis 2 weeks after commencing adjuvant therapy. Imaging revealed two thoracic extradural lesions and florid vertebral and pulmonary metastases. This is the first report in indexed literature of a primary intracranial ES on the skull-base with disseminated extracranial disease.

Pituitary tumor apoplexy in patients with Cushing’s disease: endocrinologic and visual outcomes after transsphenoidal surgery

Pituitary apoplexy in patients with adrenocorticotropic hormone (ACTH) producing tumors is a rare occurrence. We report four patients with Cushing's disease harboring ACTH-secreting macroadenomas who presented with pituitary apoplexy. We report the endocrinologic and visual outcomes of these patients after emergent transsphenoidal surgery. A retrospective chart review was performed in 4 patients who presented with pituitary apoplexy from hemorrhage into an ACTH-secreting pituitary adenoma. The patient charts were reviewed for clinical presentation, neuroimaging findings, intraoperative surgical findings, pathologic findings, and postoperative endocrinologic and visual outcomes. All patients presented with acute headaches, nausea, vomiting, and visual loss from optic compression. MR imaging demonstrated a hemorrhagic macroadenoma that was confirmed at surgery. All patients underwent emergent transsphenoidal decompression (within 24 h of presentation). One of these underwent an additional craniotomy to resect residual tumor. Postoperatively, all patients showed significant improvement in visual acuity and visual fields with biochemical remission confirmed on laboratory testing. Significant weight loss as well as resolution of diabetes and hypertension was noted in all cases. All four patients remained in biochemical remission at their most recent follow-up visit (mean 40 months, range: 24-72 months). Excellent endocrine and visual outcomes can be achieved after emergent transsphenoidal surgery in patients with Cushing's disease presenting with pituitary apoplexy. Although the cure rates of non-apoplectic ACTH macroadenomas are generally poor, higher rates of remission can be achieved in cases of pituitary apoplexy. This may be partly due to the effects of tumor infarction.

Rathke cleft cyst presenting with hyponatremia: an unusual presentation

The authors report a case of Rathke cleft cyst presenting with severe hyponatremia. A 33-year-old man suffered sudden severe headaches, visual changes, dizziness, nausea, vomiting, and a metallic taste in his mouth. Initial laboratory values demonstrated severe hyponatremia. Magnetic resonance imaging revealed a cystic lesion with questionable intracystic hemorrhage, concerning for pituitary apoplexy. Transsphenoidal decompression and drainage of the cyst confirmed the diagnosis of Rathke cleft cyst and resolved the symptoms. Postoperative follow-up studies at 6 months demonstrated normal endocrine function and no evidence of a cyst.

Intraoperative magnetic resonance imaging and early prognosis for vision after transsphenoidal surgery for sellar lesions

Sellar lesions with suprasellar extension may cause loss of visual acuity and visual field damage due to compression of the optic chiasm. Using intraoperative MR (iMR) imaging to detect symptomatic lesion remnants adjacent to the optic chiasm (that may be resected in the same procedure) may positively affect the functional outcome of patients with these lesions. The aim of this study was to evaluate the correlation between visual improvement and optic nerve decompression detected by iMR imaging in patients undergoing transsphenoidal resection of pituitary lesions. A total of 32 patients (23 men and 9 women) who underwent transsphenoidal resection of sellar lesions causing visual impairment were included in this study. Tumor volume ranged from 0.9 cm(3) to 55.7 cm(3) (mean 9.8 ± 11.7 cm(3)). Preoperative assessment showed visual field damage in 31 patients (97%) and loss of visual acuity in 28 patients (88%). The latency period between the appearance of symptoms and transsphenoidal decompression was 14.9 ± 19.5 weeks. Intraoperative MR imaging was performed after the resection was believed to be complete, or if further tumor removal was not safely possible due to changed conditions in the surgical field. Complete resection was detected on these initial scans in 17 patients (53%). Partial resection was achieved in 9 patients (28%) and tumor debulking in 6 (19%). Additional resection was possible in 8 (53%) of these 15 patients. Four (50%) of these 8 cases had suprasellar remnants and the optic chiasm was subsequently decompressed. In 5 cases optimal decompression of the optic chiasm was not possible. On early follow-up within 1 month after surgery, overall improvement of visual field damage was observed in 27 patients (87%). In 23 patients (74%), the Goldmann perimetry demonstrated complete recovery. Improvement of visual acuity was noted in 24 patients (86%). Eighteen patients (64%) regained full visual acuity. Identification of a decompressed optic chiasm on iMR imaging was significantly correlated with visual field improvement (p = 0.0007; positive predictive value 0.96, 95% CI 0.81-0.99) and relief of visual acuity deficits (p = 0.0002; positive predictive value 0.96, 95% CI 0.79-0.99). Two patients needed transcranial procedures for symptomatic tumor remnants detected on iMR imaging. Intraoperative MR imaging findings correlate with prognosis of visual deficits after transsphenoidal decompression of the anterior optic pathways. The use of iMR imaging may prevent revision surgery for unexpected symptomatic remnants.

Apoplexy in sellar metastasis; a case report and review of literature

Apoplexy in sellar metastasis is very rare with only a few case reports in literature. A case of apoplexy in sellar metastasis from follicular thyroid carcinoma is reported and the literature is briefly reviewed. The patient presented with sudden onset headache and bi-lateral loss of vision following thyroidectomy in a case of follicular carcinoma thyroid with proven sellar metastasis. CT scan showed hyperdense blood in sellar mass suggestive of apoplexy in sellar metastasis. The patient underwent early trans-sphenoidal decompression. Apoplexy in sellar metastasis, although very rare, can be clinico-radiologically indistinguishable from pituitary apoplexy and should be especially considered in the differential diagnosis of patients with known primary neoplastic disease. In view of similar patho-physiological mechanism, sellar metastasis with apoplexy should be managed in a similar manner as pituitary apoplexy.

Pituitary infiltration by non-Hodgkin's lymphoma: a case report

IntroductionPituitary adenomas represent the most frequently observed type of sellar masses; however, the presence of a rapidly growing sellar tumor, diabetes insipidus, ophthalmoplegia and headaches in an older patient strongly suggests metastasis to the pituitary. Since the anterior pituitary has a great reserve capacity, metastasis to the pituitary and pituitary involvement in lymphoma are usually asymptomatic. Whereas diabetes insipidus is the most frequent symptom, patients can present with headaches, ophthalmoplegia and bilateral hemianopsia.Case presentationA 70-year-old woman with no previous history of malignancy presented with headaches, right oculomotor nerve palsy and diabetes insipidus. As magnetic resonance imaging revealed a sellar mass involving the pituitary gland and infundibular stalk, which also extended into the right cavernous sinus and sphenoid sinus, the patient underwent an immediate transsphenoidal decompression surgery. Her prolactin was 102.4 ng/ml, whereas her gonadotropic hormone levels were low. A low level of urine osmolality after overnight water deprivation, along with normal plasma osmolality suggested diabetes insipidus. Histological examination revealed that the mass had been the infiltration of a high grade B-cell non-Hodgkin's lymphoma involving respiratory system epithelial cells. Paranasal sinus computed tomography scanning and magnetic resonance imaging of the thorax and abdomen were performed. Since magnetic resonance imaging did not reveal any abnormality, after paranasal sinus computed tomography was performed, we concluded that the primary lymphoma originated from the sphenoid sinus and infiltrated the pituitary. Chemotherapy and radiotherapy to the sellar area were planned, but the patient died and her family did not permit an autopsy.ConclusionLymphoma infiltration to the pituitary is difficult to differentiate from pituitary adenoma, meningioma and other sellar lesions. To plan the treatment of lymphoma infiltration of the pituitary gland, it must be differentiated from other sellar lesions.