Intrasellar cysticercosis cyst treated with a transciliary supraorbital keyhole approach – A case report

Background: Neurocysticercosis is the most common parasitic disease affecting the central nervous system. Isolated sellar cysticercosis cysts are rare and can mimic other sellar lesion as cystic pituitary adenoma, arachnoid cyst, Rathke cleft cyst, or craniopharyngioma. The surgical resection is mandatory because the cysticidal drugs are ineffective, however, new microsurgical approaches are emerging to reduce complications and need to test in this condition. We present a patient with a sellar cysticercosis cyst treated by transciliar supraorbital keyhole approach. Case Description: A 45-year-old female with presented with chronic severe headaches, progressive deterioration of 6 months in visual acuity and bitemporal hemianopia. The pituitary hormonal levels were normal. Magnetic resonance findings showed a sellar and suprasellar cyst and underwent a microsurgical supraorbital transciliar keyhole approach for lesion resection. Pathologically, the lesion demonstrated a parasitic wall characterized by wavy, dense cuticle, and focal globular structure, surrounding inflammatory reaction with plasma cells. Postoperatively, the patient recovery fully neurologically. Conclusion: Intrasellar cysticercosis cyst causes significant neurological deficits due to its proximity to the chiasm, optic nerves, pituitary stalk, and the pituitary gland. Surgical section is an effective treatment. The supraorbital keyhole craniotomy offers satisfactory exposure, possibility of total resection with dissection of the supra and parasellar structures, short operative time, less blood loss, short hospital stay, and good overall surgical outcome.

Prospective Evaluation of Incidental Pituitary Imaging Findings in the Sella Turcica

Purpose Reported rates of incidentally discovered pituitary sellar lesions vary widely, at least in part because of the inadvertent inclusion of patients with a history suspicious for a pituitary disorder. We prospectively evaluated the incidence of truly incidental sellar findings detected on imaging at a large academic medical center. Methods Deidentified data were extracted from the electronic medical record of adults who underwent diagnostic computed tomography (CT) or magnetic resonance imaging (MRI) over a 1-year period for any cause unrelated to known or suspected pituitary disorder both in inpatient and outpatient settings. Patients with International Classification of Diseases, Ninth Revision, (ICD-9) and Tenth Revision (ICD-10) codes indicative of a sellar lesion and those with symptoms suggestive of sellar/parasellar mass effects were excluded. Results Of 9572 scans performed during the 1-year study period, 3840 met the inclusion criteria to comprise the study cohort; 13 were manually excluded because of findings or symptoms of sellar masses not otherwise captured. The overwhelming majority of evaluable images (n = 3782) showed no sellar lesions. Truly incidental sellar findings were detected in 45 (1.2%), most commonly among inpatients (P < .001). Partially empty sella and empty sella were the most frequent findings, and were twice as likely to be detected on MRI vs CT. All other incidentally discovered lesions, including one microadenoma and one macroadenoma, were detected only by MRI. Conclusion Frequency of incidental sellar lesions in patients with no known or suspected history of pituitary disorder is low. Given the small likelihood of aggressive behavior in these lesions, the clinical significance of truly incidentally discovered sellar lesions should not be overestimated.

A sellar neuroblastoma showing rapid growth and causing syndrome of inappropriate secretion of antidiuretic hormone: A case report

Background: Sellar neuroblastoma is a very rare entity. We report a rare case of arginine vasopressin (AVP)- producing sellar neuroblastoma presumed to have originated from the lower part of sellar turcica, which grew very rapidly. Case Description: A 33-year-old woman was found to have a sellar lesion with a diameter of 18 mm invading into the bilateral cavernous sinus on magnetic resonance imaging (MRI) performed for dizziness. Six years later, when she visited the clinic due to bilateral visual disturbance, MRI showed a rapid growth of the tumor, with a maximal diameter of 56 mm at the current state, strongly compressing the optic nerve and chiasm. Transsphenoidal decompression of the optic chiasm revealed an intact pituitary gland on the top of the tumor. The tumor was composed of neoplastic cells that were immunohistochemically positive for neuronal markers and arginine vasopressin (AVP), but negative for all anterior pituitary hormones, glial fibrillary acidic protein, or thyroid transcription factor-1; these findings were suggestive of sellar neuroblastoma. She underwent 50-Gy radiation therapy, which has controlled the growth for the past 3 years. Conclusion: Awareness of rare sellar neuroblastomas will allow the accumulation of clinicopathologic information that may facilitate the understanding of their origin, clinical features, neuroimaging characteristics, and pertinent adjuvant treatment.

Endoscopic Transsphenoidal Hypophisectomy versus Microscopic Transsphenoidal Surgery in the Treatment of Pituitary Adenomas: Evaluation of Results in Terms of Ophthalmic Affection

BACKGROUND: Neurophthalmologic examination is part of the baseline evaluation of patients with pituitary lesions. The neuro-ophthalmologist quantifies and evaluates the impact that the sellar lesion has on afferent and efferent visual pathways, contributes to the determination of tumor growth dynamics, and monitors the success and possible complications. In cases of vision loss, blurring, damage, or double vision as symptoms of a clinical presentation, the neuro-ophthalmologist is often the first to recognize and define the pituitary lesion. AIM: The aims of this study are as follows: First, to determine the comparative difference and value of the axis/width of the field of vision in the comparable resection technologies, i.e. fully endoscopic and microscopic/microscopic-assisted hypophysectomy; and second, the extend of resection in both technologies compared with post-operative outcome analysis. METHODS: The study was designed as a retrospective-prospective clinical trial in the period of 2011–2017. This study enrolled 85 patients, 46 of whom were treated with a microscopic resection, and 39 patients treated only with endoscopic transsphenoidal resection of pituitary adenomas as the subject of this study. RESULTS: The results of our analysis showed that the achievement of complete, radical, and subtotal resection is significantly higher in the endoscopic technique compared to the microscopic technique. Essentially, better lighting, better viewing angle with no “blind spots,” and a perfected toolkit of instruments are the objective factors for progress. CONCLUSION: The results of our study, comparing the endoscopic version of the microscopic transnasal, transsphenoidal resection of pituitary adenomas, during the period 2010–2018, have unequivocally shown that the endoscopic transnasal transsphenoidal procedure is rational, effective, efficient, and above all safe technique, with a number of favorable advantages that allow for a higher degree of surgical radicality.

MON-251 Xanthogranulomatous Hypophysitis: A Rare Case of Hypopoituitarism

The patient is a 54-year-old male with type 2 diabetic treated with insulin who presented with a two-week history of fever nausea and vomiting. He subsequently developed seizure episodes with changes in mental status prompting a visit to the emergency room. Upon admission the patient was hypotensive and lethargic. After an initial improvement, he developed polyuria (14-15 liters per day) in the context of eunatremia and specific gravity of 1010. His initial evaluation revealed a serum a.m. cortisol of 1.2 mcg/dL (6.2 to 19.4), low free T4 of 0.64 Ng/dl) 0.9-1.7) and secondary hypogonadism with a total testosterone of less than 2.5 ng/dL (181-772). Hormonal replacement was initiated. MRI of the brain revealed heterogeneous sellar lesion measuring 2.1 x 2.0 x 2.0 cm with peripheral enhancement following contrast administration and deviation of the pituitary stalk to the right. The lesion invaded the left cavernous sinus (Knosp III) and abutted the optic chiasm. He underwent an uneventful transsphenoidal tumorectomy revealing extensive coagulation necrosis with chronic lymphocytic infiltration, numerous macrophages and multinucleated giant cells with deposits of hemosiderin, cellular debris and isolated cholesterol crystals surrounded by granulomatous tissue. The pathology was compatible with xanthogranulomatous hypophysitis. We report a rare case of Xanthogranulomatous hypophysitis (XGH), the least common subtype of pituitary hypophysitis often mistaken by a neoplastic lesion. It is more common in young adults occurring in isolation, as a secondary reaction to a local process such as apoplexy part or as part of a systemic condition with autoimmune aetiology, often resulting in variable degrees of anterior and posterior pituitary deficiencies.

Sellar Colloid Cyst—An Anatomically Aberrant and Diagnostically Challenging Entity: Report of a Rare Case with Literature Review

The sellar colloid cyst is a rare entity anatomically occurring at the intermediate lobe of the pituitary gland. Clinically a cystic sellar lesion with pressure effects usually evokes the suspicion of a pituitary adenoma. We present the case of a middle-aged woman presenting with visual diminution and bilateral optic atrophy, caused by a large sellar lesion, variably intense on magnetic resonance imaging (MRI). The subsequent histologic diagnosis of a colloid cyst was unexpected. This report highlights the subtle intraoperative and diagnostic features key to diagnosing this rarity. We also discuss a practical differential diagnostic approach relevant to the practicing surgeon and review the existing literature.

TWO SYNCHRONOUS PITUITARY ADENOMAS CAUSING CUSHING DISEASE AND ACROMEGALY

Objective: To report the first case of 2 synchronous pituitary adenomas, 1 corticotroph and 1 somatotroph, with distinct molecular lineages confirmed by differential hormone and S-100 protein expression. Methods: A case report followed by a literature review are presented. Results: A 68-year-old woman presented for evaluation of resistant hypertension. Biochemical testing demonstrated adrenocorticotropic hormone (ACTH)-dependent hypercortisolemia and growth hormone (GH) excess. Pituitary magnetic resonance imaging (MRI) revealed a 2 cm left sellar lesion consistent with a pituitary macroadenoma. The patient therefore underwent transsphenoidal surgery for a presumed cosecreting ACTH and GH macroadenoma. Tumor immunohistochemical staining (IHC) was positive for ACTH, but negative for GH. Postoperative biochemical testing confirmed remission from Cushing disease, but the insulin-like growth factor 1 (IGF-1) level remained elevated. Postoperative MRI demonstrated a small right sellar lesion that, in retrospect, had been present on the preoperative MRI. Resection of the right lesion confirmed a GH-secreting adenoma with negative ACTH staining. After the second surgery, the IGF-1 level normalized and blood pressure improved. Further pathologic examination of both surgical specimens demonstrated differential expression of S-100 protein, a folliculostellate cell marker. Reverse transcription polymerase chain reaction of messenger ribonucleic acid from the left sellar lesion was positive for ACTH and negative for GH, confirming the IHC results. Germline mutations in genes known to be associated with pituitary adenoma syndromes ( MEN1, CDC73, CDKN1A, CDKN1B, CDKN2B, CDKN2C, and AIP) were not detected. Conclusion: Although the pathogenesis of synchronous pituitary adenomas has not been fully elucidated, this case report suggests that they can have distinct molecular lineages.

P43 Parasellar capillary haemangioma with intrasellar extension

ObjectivesCapillary haemangioma is a benign vascular tumour that typically arises from skin and mucosal surfaces at birth and in infants. Central nervous system (CNS) capillary haemangioma in adults is extremely rare. We describe a case of capillary haemangioma located within the parasellar region extending into the sella.DesignCase report.ResultsWe report a 64-year-old patient who presented with a short history of ptosis and left sided headaches. CT showed a 3 cm by 2.5 cm para-sellar lesion extending into the sella. MRI showed a homogenously hyperintense lesion on T2-weighted MRI and FLAIR, which was isointense with adjacent brain parenchyma on T1-weighted MRI. This lesion also demonstrated contrast enhancement. The patient underwent an initial endoscopic transsphenoidal biopsy, which was inconclusive, followed by a craniotomy and debulking. Histological examination revealed fibrous tissue containing numerous thin walled and irregular vascular channels of varying sizes. There was a mild associated inflammatory infiltrate, mainly formed of small mononuclear chronic inflammatory cells, and occasional histiocytes. The histological appearances were in keeping capillary haemangioma.ConclusionsThe present case describes a capillary haemangioma located in the sella. The rarity of this vascular entity and the absence of any pathognomonic imaging features make it difficult to diagnose based on radiological appearances alone. Although rare, CH should be a differential when considering a sella or parasellar lesion.

Pituitary Abscess: A Rare Clinical Entity in the Presence of Acute Rhinosinusitis: A Case Report

A pituitary abscess is an often-overlooked diagnosis in the clinical presentation of a sellar mass. Due to its rare incidence and nonspecific presentation, diagnosis and treatment is often delayed. The authors describe a 56-year-old male patient presenting with acute onset of severe headache, visual field deficit, and radiologic findings of an expansile sellar lesion. The presenting symptoms were unremarkable for the diagnosis of meningitis, cavernous sinus thrombosis, and septicemia. Recent medical history included symptoms of rhinosinusitis on the days preceding his acute presentation. The initial clinical presentation was suggestive of a possible pituitary apoplexy. Intraoperative findings revealed purulent output upon surgical entry of the sella. Histopathology confirmed the diagnosis of a pituitary abscess. Review of the clinical and radiologic data revealed evidence of multiple opacifications within the paranasal sinuses, along with dehiscence overlying the sellar bone, supporting a diagnosis of secondary pituitary abscess. This case, along with a review of the available literature, will serve to expand our knowledge of this rare disease process that is often overlooked. Clinicians should be mindful of this condition, and include a primary versus secondary pituitary abscess in the differential workup on such cases.