A case of metastatic tumor of the pituitary gland presenting as a subarachnoid hemorrhage

We reported the case of a 55-year-old man with metastatic tumor of the pituitary gland who suffered from symptomatic pituitary apoplexy with subarachnoid hemorrhage. The patient, who had sigmoid colon carcinoma and left parietal metastatic brain tumor, developed severe headache and decrease of right visual acuity. CT showed a pituitary mass with subarachnoid hemorrhage. Transsphenoidal surgery was performed after replacement therapy with corticosteroids. Histological examination revealed metastasis of adenocarcinoma. Pituitary apoplexy is an unusual manifestation of metastatic pituitary tumor. The case of metastatic tumor of the pituitary gland presenting as subarachnoid hemorrhage such as this case is especial rare.     

Pituitary metastasis from carcinoma of the urinary bladder mimicking pituitary apoplexy--case report

A 70-year-old male presented with pituitary metastasis from transitional cell carcinoma of the urinary bladder manifesting as sudden headache, transient unconsciousness, and visual disturbance mimicking apoplexy of pituitary adenoma. Computed tomography showed a suprasellar tumor with intratumoral and intraventricular hemorrhage. Magnetic resonance imaging demonstrated an intra- and suprasellar mass lesion mimicking pituitary adenoma. Diabetes insipidus developed soon after. The tumor was subtotally removed. Histological examination revealed transitional cell carcinoma. An intratumoral hemorrhage may be associated with a pituitary metastasis if the patient presents with symptoms such as pituitary apoplexy.     

Pituitary apoplexy with localized hematoma in the suprasellar region

The authors report a case of a patient with a pituitary tumor, in which pituitary apoplexy occurred only in the suprasellar part of the tumor. A 26-year-old woman suffered from abrupt worsening of vision and headache. A CT scan showed a dumb-bell-shaped tumor extending to the suprasellar region, in which an irregularly shaped low density area suggesting a liquidized hematoma was seen. The rapid worsening of her symptoms was highly indicative of pituitary apoplexy. The first operation was performed through the transsphenoidal route. There was no evidence of intratumoral hematoma in the intrasellar tumor, which could be removed successfully. However, the suprasellar mass could not be reached because of the hardness of the diaphragma sellae and the presence of a normal pituitary gland. MRI and CT cisternography after this first operation showed a narrow opening of the diaphragma sellae. The second operation using right frontotemporal craniotomy disclosed a suprasellar mass, which consisted of an old hematoma and a necrotic tumor. The tumor was sub-totally removed. The patient's visual acuity improved after the second operation. Although transsphenoidal surgery is the treatment of choice in patients with pituitary apoplexy, the selection of the surgical route should be made only after careful neuroradiological evaluation with regard to the extrasellar extension of the tumor.     

An elderly case of craniopharyngioma: treatment by limited surgery and radiation therapy

Craniopharyngioma accounts for approximately 3.5% of all intracranial neoplasm and may occur at any age. However craniopharyngioma in the elderly was rare. We report a rare case of craniopharyngioma in an elderly patient, who was treated by radical surgery successfully. An 80-year-old male was admitted to our hospital with a history of visual disturbance and bitemporal hemianopsia. CT scan of the brain revealed a hypodense cystic mass with calcification in the suprasellar area. MRI demonstrated the optic chiasm was displaced superiorly. Her symptom deteriorated day short time of her hospitalized life. We decided to removal tumor radically because of saving her visual function. Subtotal removal of the suprasellar lesion was performed, followed by radiotherapy to the residual lesion. A visual impairment was improved after surgery. No recurrences had been detected on MRI eighteen months after the initial operation. Based on previous report and the clinical course of our case, radical surgery is sometimes needed for saving visual function in spite of elderly patient. However, in this case, sparing hypothalamic and pituitary function is essential for good prognosis.     

Symptomatic intrasellar arachnoid cyst: case report

A case of a large symptomatic intrasellar arachnoid cyst with suprasellar extension is reported. A 53-year-old man was admitted because of decreased visual acuity. Magnetic resonance imaging showed a large intrasellar cyst extending into the suprasellar cistern, with compression of optic nerves. The intensity of the cyst was identical to that of the surrounding subarachnoid space on both T1-, T2-, and proton density-weighted images. Transsphenoidal surgery was performed, but subsequent refilling of the cyst required additional transcranial surgery. Analysis of the cerebrospinal fluid-like cystic fluid revealed high levels of protein and pituitary hormones. Histological study revealed that the cyst wall was composed of connective tissue and arachnoid cells, which were ultrastructurally characterized by a number of desmosomes. Diagnostic, surgical, and pathological features of intrasellar arachnoid cysts are discussed.     

Laparoscopic Anterior Lumbar Interbody Fusion Precipitating Pituitary Apoplexy

Summary  Objective. Pituitary apoplexy may be the first presentation of a previously undiagnosed pituitary adenoma. Although many mechanisms of pituitary apoplexy have been proposed in the literature, the exact pathogenesis remains unclear. Many predisposing events have been implicated in the pathogenesis, however, the role of laparoscopy precipitating pituitary apoplexy has not been previously described. The authors present a case of pituitary apoplexy in a previously undiagnosed pituitary adenoma, which presented in the immediate post-operative period after a laparoscopic anterior lumbar interbody fusion.  Clinical Presentation. A 45-year-old man presented with a sudden onset of headache, photophobia, diplopia, visual field deficits, and decreased visual acuity in the immediate post-operative period after an uneventful laparoscopic anterior lumbar interbody fusion. Results of computed tomography of the brain revealed a hyperdense suprasellar mass without any signs of subarachnoid blood. The patient underwent magnetic resonance imaging, which revealed a hemorrhagic pituitary tumor with lateral and suprasellar extension, with compression of the cavernous sinus and optic chiasm, respectively. An urgent transsphenoidal decompression of the hemorrhagic pituitary adenoma was performed. Post-operatively, the patient demonstrated marked neurological improvement with recovery of visual acuity and extraocular movements.  Conclusion. To the authors' knowledge, this is the first case reported in the literature of a laparoscopic procedure precipitating pituitary apoplexy. Recognition of this rare complication of laparoscopic surgery, and the importance of rapid diagnosis and urgent surgical treatment are emphasized.     

A case of prolactinoma associated with craniopharyngioma

A surgical case of prolactinoma associated with craniopharyngioma is reported. A 47-year-old man was admitted to some neurosurgical clinic on October 12, 1982, because of visual disturbance, general fatigue and impotence. Laboratory study revealed hyperprolactinemia (360 ng/ml) and slight enlargement of sella turcica indicated the pituitary adenoma. Transsphenoidal surgery was performed to remove the tumor on November 20, 1982. Histopathological examination revealed chromophobe adenoma, and prolactin was stained in the tumor cells by means of immunoperoxidase staining. Though the clinical symptoms had been improved after surgery, visual disturbance became worse about one month later. At that time empty sella syndrome was suspected and the second operation (interhemispheric approach) was performed on January 21, 1983. No pathological changes were observed at all. On July 13, 1983, he was transferred to our clinic, because his visual acuity was deteriorating. At this time we reviewed the previous CT scan and noticed a suprasellar mass. It was supposed that the lesion had been overlooked and was the cause of the visual disturbance. On August 1, 1983, a bifrontal craniotomy was performed and the suprasellar tumor was removed. Pathological examination of the tumor revealed craniopharyngioma. So it was supposed that pituitary adenoma and craniopharyngioma had been coexisting since onset. Except for cases with von Recklinghausen's disease, multiple primary intracranial tumors of different cell types are relatively rare. A review of literature revealed 94 cases until 1986. The most frequent combination of multiple tumors was meningioma and glioma. But we could not find any case of pituitary adenoma associated with craniopharyngioma in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pituitary Apoplexy Caused by Hemorrhage From Pituitary Metastatic Melanoma: Case Report

Melanoma metastases to the pituitary gland are extremely rare, with only a few reported cases. We report an unusual case of pituitary metastatic melanoma in which the patient presented with pituitary apoplexy. A 68-year-old man presented general fatigue and anorexia following sudden headache. Neurological examination disclosed bitemporalhemianopsia. Computed tomography (CT) scans revealed a suprasellar mass including intratumoral hematoma. Magnetic resonance (MR) images demonstrated a circumscribed mass lesion in the intra- and suprasellar regions, compressing the optic chiasm. Surgical exploration was performed through a transsphenoidal approach, and a mixture of tumor and necrotic tissue with old hematoma was obtained. The histological examination of the specimen revealed a partly necrotic, malignant tumor with focal melanotic pigmentation. Histopathologically, the diagnosis was consistent with pituitary apoplexy caused by hemorrhage from pituitary metastatic melanoma.     

Evaluation of the transcranial approach to pituitary adenomas based on quantitative analysis of pre- and postoperative visual function

Over a 16-year period, 105 patients with pituitary adenoma accompanied by visual disturbance underwent transcranial intracapsular removal of the tumor followed by radiotherapy. Postoperative recovery of visual function in these patients was compared with the results obtained in other institutions after trans-sphenoidal surgery. The severity of preoperative visual impairment was correlated with the duration of visual impairment, the degree of optic atrophy, the extent of suprasellar tumor infiltration, and age. Trans-sphenoidal surgery appears more effective in patients with mild preoperative visual disturbance, whereas the transcranial approach yields better results in patients with moderate to severe preoperative visual deficits.     

An interesting case of a pituitary adenoma apoplexy mimicking an acute meningitis. Case report

Apoplexy of a pituitary adenoma is a rare and under-diagnosed clinical occurrence. It results from either infarction or haemorrhage into an adenoma of the pituitary gland. Its clinical presentation more often includes rapid development of impaired consciousness, severe headache, visual disturbance and variable association of oculomotor nerve palsy. Meningeal irritation signs are considered very rare and usually not reported as presenting symptoms. A 33-year-old male suffered a pituitary macroadenoma apoplexy, clinically indistinguishable from an infectious meningitis at presentation. Three days after surgery, the patient developed a left ophthalmoplegia due to 3(rd) nerve palsy, which fully resolved within 2 months. A right pterional craniotomy was performed during which complete tumour removal was achieved. In conclusion the authors believe that, despite many reports in the literature, encouraging conservative management in pituitary apoplexy by administering intravenous steroids, surgery should be undertaken in order to avoid eventual visual field defects, relieve pituitary gland compression and prevent a possible recurrent apoplectic episode or tumor re-growth.     

Pituitary cyst presenting with hyponatremia and increased secretion of brain natriuretic peptide. Case report

In most cases of pituitary cyst there are no clinical symptoms and the lesions are found incidentally. The authors report the case of a 60-year-old man with a pituitary cyst causing visual disturbance and hyponatremia. The patient presented with appetite loss and general fatigue. On admission, blood workup showed severe hyponatremia (112 mEq/L), and bitemporal hemianopsia was observed on neurological examination. Magnetic resonance imaging revealed an intra- and suprasellar region cystic mass extending to the frontal base and hypothalamic area. The serum level of brain natriuretic peptide (BNP) was elevated (92 pg/ml) with polyuria and excessive Na excretion. Transsphenoidal surgery was performed to drain the cyst. The cyst wall was partially excised and the cystic fluid was aspirated. The secretion of BNP normalized postoperatively, and the hyponatremia and visual symptoms resolved. Histological examination, including an electron microscopy study, confirmed the diagnosis of a simple cyst. This appears to be the first reported case of a pituitary simple cyst associated with hyponatremia and an elevated BNP level.     

Difficulté du diagnostic différentiel entre l’apoplexie hypophysaire et le craniopharyngiome

Pituitary apoplexy is characterized by an abrupt neurological deteriorating condition associated with rapid expansion of the pituitary gland, caused by ischemic necrosis and hemorrhage. Craniopharyngioma may be difficult to distinguish from pituitary apoplexy. In this study, we discuss a case of pituitary apoplexy in a 19-year-old male patient. In our patient, the tumor was confused with a craniopharyngioma because of the suprasellar extension of the tumor on magnetic resonance (MR) images and the hyperintensity in T1-weighted images, the young age of the patient, and the gradually progressive onset of the symptoms. In conclusion, even without a known history of pituitary adenoma or an abrupt onset of the clinical symptoms, the diagnosis of pituitary apoplexy should be considered in a patient with a suprasellar mass hyperintensity in T1-weighted MR images, which may mimic craniopharyngioma.     

Endonasal transsphenoidal surgery under local anesthesia for elderly patient with pituitary tumor: case report

We present a surgical case under local anesthesia of an 88-year-old woman suffering from visual disturbance caused by pituitary adenoma. Magnetic resonance (MR) imaging showed a large pituitary tumor with suprasellar extension compressing the chiasmatic nerve. Neither she nor her family would agree to surgical therapy. However, when we proposed surgery under local anesthesia, they accepted it. Partial removal of the tumor via the endonasal transsphenoidal approach was carried out, uneventfully. The nasal surface was infiltrated with 4%-Xylocaine prior to the ordinary xylocaine injection to the nasal mucosa. The patient did not complain of any pain associated with the surgical procedure, including saline injection to the subarachnoid space through spinal drainage. The postoperative course was fine except for the temporarily appearance of diabetes insipidus. Postoperative MR imaging showed complete relief of compression to the chiasmatic nerve. Her visual field was improved dramatically. Endonasal transsphenoidal surgery under local anesthesia is thought to be one of the most useful methods of choice, especially in cases of elderly patient with pituitary tumor.     

Cerebral infarction following pituitary apoplexy--case report

A 29-year-old man presented with lethargy, headache, high fever, and visual disturbance. Neurological examination showed mydriatic pupil, ptosis, diminished light reflex, and ophthalmoplegia on the left. Magnetic resonance (MR) imaging showed the typical findings of pituitary apoplexy, and cerebral angiography disclosed mild narrowing of the A1 segment of the left anterior cerebral artery (ACA). Transsphenoidal tumor resection was performed. Transient severe right hemiparesis occurred directly after the operation. Computed tomography demonstrated cerebral infarction in the territory of the left Heubner's and medial lenticulostriate arteries. Pituitary apoplexy followed by cerebral infarction is very rare. Vasospasm of the perforating arteries of the ACA probably caused the cerebral infarction. Subarachnoid blood or vasoactive agents released from the tumor were the most likely cause of the vasospasm. MR imaging findings of contrast enhancement around the vessels may indicate reactive processes around the vessels.     

A case of metastatic suprasellar tumor with edema along the optic pathway

A rare case in presented of a patient with edema formation along the optic pathway, which was caused by metastatic suprasellar tumor mimicking craniopharyngioma. A 63-year-old female with visual disturbance, diabetes insipidus, and symptomatic panhypopituitarism was admitted to our hospital. CT images showed a suprasellar mass lesion. MR images demonstrated a heterogeneously enhanced tumor and edema along the optic nerve and tract. Although no cystic component is shown in radiological findings, these features are commonly observed in cases of craniopharyngioma. The patient underwent removal of the tumor by the transcranial approach. Since histological examination revealed adenocarcinoma, the tumor was diagnosed as metastatic brain tumor originating from non-recurrent rectal cancer operated on eight years previously. Conventional radiotherapy with a dose of 50GY was performed for the residual tumor. The tumor size was unchanged, but the edema had disappeared 7 months after the operation. Edema spreading along the optic tract was reported as a characteristic MR finding for diagnosis of craniopharyngiomas as distinguished from other common parasellar tumors. However, it is suggested that edema of the optic pathway seems to be caused not only by craniopharyngioma but also other suprasellar lesions. Even if there was a characteristic radiological finding for some specific diseases, metastasis should be kept in mind as a differential diagnosis, because of its various appearance in neuroimages.     

Pituitary apoplexy causing internal carotid artery occlusion--case report

A 50-year-old man presented with pituitary apoplexy resulting in internal carotid artery occlusion manifesting as sudden onset of severe headache, right ptosis, and left hemiparesis, associated with visual impairment. Computed tomography showed a nodular mass, located in the sellar and suprasellar regions with early signs of acute cerebral ischemia. Magnetic resonance (MR) imaging indicated that the mass compressed the bilateral cavernous sinuses, resulting in obliteration of the cavernous portion of the right internal carotid artery. Right middle cerebral artery territory infarction was also found. Conservative therapy with steroids was given in the acute stage and repeated MR imaging showed recanalization of the internal carotid artery with reduction of the tumor size. The tumor was removed through the transsphenoidal approach to obtain a definitive diagnosis in the chronic stage. The histological diagnosis was consistent with non-functioning pituitary adenoma. Eye movement of this patient showed full recovery after the operation. Pituitary apoplexy resulting in internal carotid artery occlusion is rare. Surgical decompression through the transsphenoidal approach is appropriate, but the optimal timing should consider severe disturbance of visual acuity and visual field in the acute stage.     

A case of intrasellar pure germinoma

A 19-year-old male presented with progressive loss of vision and diabetes insipidus due to an intra- and suprasellar tumor. Transsphenoidal exploration revealed a pure germinoma. Seven days after the operation, bleeding from the residual tumor caused headache and right occulomotor palsy. The residual tumor and hematoma were removed using pterional approach. The residual tumor disappeared after postoperative irradiation. After 5 months of radiation, multiple lesions due to dissemination of the germinoma were discovered in the suprasellar region. Adjuvant chemotherapy and whole supratentorial irradiation were performed. All lesions regressed completely. Mid-sagittal magnetic resonance image was useful in our patient for differential diagnosis between intrasellar germinoma and pituitary adenoma. Before initiating an operation for intrasellar germinoma, awareness is needed for the fact of postoperative bleeding. We notice that transsphenoidal surgery should be selected for treatment of postoperative bleeding from intrasellar germinoma.     

Resection of suprasellar tumors by using a modified transsphenoidal approach. Report of four cases

Generally accepted contraindications to using a transsphenoidal approach for resection of tumors that arise in or extend into the suprasellar region include a normal-sized sella turcica, normal pituitary function, and adherence of tumor to vital intracranial structures. Thus, the transsphenoidal approach has traditionally been restricted to the removal of tumors involving the pituitary fossa and, occasionally, to suprasellar extensions of such tumors if the sella is enlarged. However, conventional transcranial approaches to the suprasellar region require significant brain retraction and offer limited visualization of contralateral tumor extension and the interface between the tumor and adjacent structures, such as the hypothalamus, third ventricle, optic apparatus, and major arteries. In this paper the authors describe successful removal of suprasellar tumors by using a modified transsphenoidal approach that circumvents some of the traditional contraindications to transsphenoidal surgery, while avoiding some of the disadvantages of transcranial surgery. Four patients harbored tumors (two craniopharyngiomas and two hemangioblastomas) that arose in the suprasellar region and were located either entirely (three patients) or primarily (one patient) within the suprasellar space. All patients had a normal-sized sella turcica. Preoperatively, three of the four patients had significant endocrinological deficits signifying involvement of the hypothalamus, pituitary stalk, or pituitary gland. Two patients exhibited preoperative visual field defects. For tumor excision, a recently described modification of the traditional transsphenoidal approach was used. Using this modification, one removes the posterior portion of the planum sphenoidale, allowing access to the suprasellar region. Total resection of tumor was achieved (including absence of residual tumor on follow-up imaging) in three of the four patients. In the remaining patient, total removal was not possible because of adherence of tumor to the hypothalamus and midbrain. One postoperative cerebrospinal fluid leak occurred. Postoperative endocrinological function was worse than preoperative function in one patient. No other new postoperative endocrinological or neurological deficits were encountered. This study demonstrates the feasibility of using a modified transsphenoidal approach for resection of certain suprasellar, nonpituitary tumors.     

A case of suprasellar tumor associated with so-called atypical angina pectoris]

A case of suprasellar tumor associated with so-called atypical angina pectoris was reported. A 58-year-old man was admitted to our hospital on Feb. 2, 1973, because of headache, disturbance of visual field and the attack of chest pain. He had been suffering from disturbance of visual field for about 3 years and the attack of chest pain for about 4 months prior to admission. Neurological findings on admission were bitemporal hemianopia, decreased visual acuity and atrophy of the optic disc. Bilateral carotid angiography showed upward displacement of A1 portion of the anterior cerebral artery. Pneumoencephalography demonstrated defect of the anterior part of the third ventricle. Laboratory examination showed hypopituitalism. On March 26, 1973, Right frontal craniotomy was performed under the diagnosis of suprasellar tumor. The walnut-sized tumor was detected in the suprasellar region and removed totally. Histological examination showed dermoid cyst. With regard to the attack of chest pain, the selective coronary angiography was performed. But organic change was not detected and Master's two step test did not induce any pathological finding in EEG. So we made a diagnosis of so-called atypical angina pectoris. There are many arguments about pathogenesis of so-called atypical angina pectoris. There is no organic change of the heart of attention now. Recently it is said that so-called atypical angina pectoris is closely connected with paradoxical sleep. We recognized dysunction of the autonomic nervous system through various examinations. The hypothalamus was displaced upward by a suprasellar tumor in this case. After removal of the suprasellar tumor, the frequency of the attack of chest pain was decreased. The atypical angina pectoris in the presented case may be considered to consequence of distrubance of the hypothalamic function.     

Transsphenoidal surgical treatment of pituitary adenomas in patients aged 80 years or older

To know the clinical characteristics of pituitary adenomas in the elderly patients aged 80 years or older who were surgically treated. From 1995 through 2012, 907 patients underwent surgery for the pituitary adenomas at Kagoshima- and Hiroshima University hospitals in Japan. Ten (1.1 %) patients were aged 80 years or older. We retrospectively assessed the clinical characteristics including preoperative comorbidities, manifestations, neuroimaging findings, and endocrinologic features of these ten patients. The subjects included eight males and two females. Their ages ranged from 80 to 86 with mean of 83.1 years. Of these, besides one case of growth hormone-producing adenoma, others were clinically nonfunctioning adenoma. Six patients had modest comorbidities such as hypertension, cardiovascular diseases, diabetes mellitus, or chronic kidney dysfunction, and all patients were classified into grade 2–3 on American Society of Anesthesiologists’ Physical Status grading. Transsphenoidal surgery was performed in all due to visual disturbance in eight, diabetes mellitus as an intercurrent illness of acromegaly in one, and for the purpose of preventing visual disturbance in one patient who had an adenoma impinging optic chiasm but still had normal visual field. The surgeries provided sufficient decompression of the optic pathways and improved visual disorder in all. In an acromegalic male, his comorbidities considerably improved. No permanent surgical morbidity ensued. More than three axes of anterior pituitary hormones were preoperatively impaired in all, which were rarely recovered. Transsphenoidal surgery is safe and efficient treatment way for patients aged 80 years or older with pituitary adenomas with chiasmatic symptoms when the patients’ general condition is well preserved and pituitary hormonal deficiency is adequately replaced.