Pituitary tumor apoplexy presenting as infective meningoencephalitis

We report on a case of a 80-year-old man who developed progressive drowsiness with headache, fever and signs of meningeal irritation 2 days after a head trauma. Suspecting an infective meningoencephalitis, the patient was treated with wide spectrum antibiotic and antiviral therapy. Brain CT scan revealed a previously unknown pituitary expansive lesion. A brain MRI study confirmed the presence of an intrasellar lesion, which presented remarkable contrast ring enhancement, and showed non-specific inflammatory tissue on the clivus, possibly responsible of the clinical features of sterile meningitis. A biopsy proven diagnosis of pituitary apoplexy was made. This case highlights MRI as an important investigation for earlier recognition of pituitary apoplexy that can present with a clinical picture resembling an infective meningoencephalitis.     

Tuberculous meningitis with pituitary abscess

Although rare, the possibility of pituitary tuberculoma should be considered in the diagnosis of non-pituitary intrasellar masses, especially in an endemic area and if radiologic imaging shows pituitary stalk thickening. We describe the case of a 52-year-old patient who presented tuberculous meningitis complicated by a pituitary abscess. He was treated with antituberculous drugs. The follow-up MRI 16 and 48 months later showed the decreased size of the pituitary mass. Radiological features and a review of the literature of pituitary tuberculoma are briefly discussed.     

垂体脓肿的诊断和治疗(14例报告和文献复习)

目的:探讨垂体脓肿的临床特征和治疗。方法:回顾性分析14例垂体脓肿患者的临床表现、影像学特征、诊断和治疗,并结合文献进行分析。结果:14例患者中头痛13例,垂体功能低下6例,视力视野影响6例,多饮多尿3例,发热3例。MRI增强病灶均呈环状强化。11例经蝶手术治疗,3例经开颅手术。术后随访头痛缓解者10例,视力、视野改善者4例,尿崩者2例恢复正常,垂体功能低下者中4例恢复正常,3例开颅手术者中2例复发,再经蝶手术治愈。结论:应用常规CT和MR术前诊断垂体脓肿困难,对鞍区囊性病变应考虑到垂体脓肿的可能。及早手术、正确选择手术入路、围手术期合理应用抗生素和适当的对症治疗是治疗垂体脓肿的关键。     

Intrasellar tuberculoma presenting as pituitary apoplexy.

The combination of apoplectic symptoms and a sellar mass most often points to a diagnosis of a pituitary adenoma. Sellar tuberculomas are not considered as a cause of 'pituitary apoplexy' and there has been no radiological documentation of haemorrhage associated with them. We report a 27 years old man who presented with 3 previous episodes of pituitary apoplexy. CT scan showed evidence of a sellar mass with haemorrhage. Transsphenoidal biopsy of the intrasellar mass was reported as 'tuberculoma'. The patient had marked reduction in the size of the lesion following antituberculous therapy with no recurrence of symptoms. Intrasellar tuberculomas must be considered as one of the differential diagnosis when patients present with a pituitary apoplexy.     

Intrasellar cavernous hemangioma.

Reports of intrasellar cavernous hemangioma are rare. They are usually incidental findings at autopsy, or initially mistaken for pituitary adenoma and treated accordingly. There are no specific symptoms. Cranial nerve palsy has occasionally been reported in patients with cavernous hemangioma, with or without sellar extension. However, intrasellar cavernous hemangioma with extension into the cavernous sinus resulting in oculomotor palsy has not been reported. We present a rare case of intrasellar cavernous hemangioma and discuss the diagnosis and management. Total surgical removal is recommended. However, attempts to resect the parasellar component of the lesion may be associated with high morbidity. Therefore, surgical cranial nerve decompression in the acute stage followed by stereotactic radiosurgery for the residual lesion may be an alternative.     

Pituitary abscess in a pregnant woman.

Pituitary abscess is a rare and potentially lethal condition. Pituitary abscess in a pregnant woman has not been previously described. A 38-year-old pregnant woman (34 weeks gestation) with a pituitary mass complained of a progressive headache and sudden visual impairment. She was afebrile and had no inflammatory symptoms on admission. On MRI, the preoperative diagnosis was pituitary adenoma with sphenoid sinusitis. She underwent an uncomplicated transsphenoidal procedure for removal of the pituitary mass. The next day, labor commenced and a healthy preterm baby was delivered. Pathologic examination of the intrasellar mass showed polymorphonuclear cells, debris and no tumor cells. The sellar contents were cultured and Streptococcus viridans was grown. To our knowledge this is the first case of pituitary abscess reported during pregnancy. Although the patient was pregnant, the transsphenoidal approach was safe for the mother and the fetus. Surgical drainage and antibiotic therapy are required for the definitive treatment of this condition.     

Isolated intrasellar tuberculoma mimicking pituitary adenoma.

A 37-year-old woman presenting with galactorrhea and menstrual irregularity due to an intrasellar lesion of the pituitary gland underwent transsphenoidal surgery for histopathological diagnosis and removal of the lesion. Histological findings were consistent with a tuberculoma. The post-operative course was satisfactory with resolution of galactorrhea and improved ovulatory cycle. The patient was successfully treated with a combination of surgical resection and anti-tuberculous therapy for one year, which resulted in hormonal and tuberculosis control. This patient appears unique regarding the location of the lesion and the dramatic response to surgical treatment. Although differential diagnosis of inflammatory pathologies of the intrasellar region presents difficulties, this patient demonstrates that tuberculoma should be considered.     

MR imaging and CT of pituitary abscess: Case report and review

Abstract

Pituitary abscess is a rare disorder. However, preoperative diagnosis is important to prevent a cranial approach leading to severe meningitis. A case of a 55 year-old woman with pituitary abcess is reported. The patient was admitted with a several-week history of frontal headache and no signs of inflammation. Computed tomographic (CT) scan showed a slightly low-density suprasellar expanding mass lesion with an enhanced thin wall in the pituitary region. Magnetic resonance imaging showed a homogenous high- intensity signal relative to brain parenchyma on T1 -weighted images with an enhanced thin wall and a homogenous low-intensity signal on T2-weighted images. This was histologically shown to be a pituitary abscess. Our case and review of the available literature suggest that pituitary abscess generally shows a homogenous low-density on CT scan and a homogenous low- to iso- and high-intensity signals or homogenous high- and low-intensity signals on T1- and T2-weighted images, respectively, with a cystic appearance and enhanced smooth wall. [Neurol Res 1996; 18: 495-498]     

Primary pituitary abscess: case report

Pituitary abscesses are potentially life-threatening lesions if not appropriately diagnosed and treated. The authors have operated on more than five hundred cases of pituitary tumors and only one represented a case of pituitary abscess. A 35-year-old woman was investigated for chronic frontal headache. CT scan showed a cystic sellar lesion with ring enhancement after contrast injection leading to an initial diagnosis of pituitary adenoma. She underwent a sublabial transsphenoidal approach to the pituitary gland. After dural opening, purulent material was obtained and no tumor or other associated lesion was detected. There was no evidence of current or previous septicemic illness, meningitis, cavernous sinus thrombosis or sinus infection. Cultures were negative. She was put on antibiotics and discharged after 4 weeks. Nowadays, 10 years after treatment, she is doing well, with no anterior pituitary hormone deficit. MRI shows a partially empty sella without residual lesion and the pituitary stalck is in the midline. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis.     

Intrasellar dermoid cyst mimicking pituitary apoplexy: A case report and review of the literature

Intrasellar dermoid cysts are extremely unusual lesions, with only four cases reported to date, and have not been previously reported in association with sudden-onset symptoms. Here, we present the case of an intrasellar dermoid cyst with sudden-onset symptoms mimicking pituitary apoplexy in an elderly woman. A 69 year-old woman presented with sudden onset of headache, dizziness, and decreased visual acuity. Magnetic resonance imaging of the sellar region showed an intrasellar lesion, which showed mixed hyper- and hypointense signal on T1-weighted and T2-weighted images and enhanced peripherally. Endocrine workup showed pituitary hormones within normal levels. According to these findings, the initial diagnosis of nonsecreting pituitary macroadenoma apoplexy was made. Intraoperatively, a large amount of whitish-yellow purulent material was found in the mass and the lesion was partially removed, owing to tight adhesion between remanent mass and surrounding neurovascular structures. Pathology showed a dermoid cyst with abundant neutrophil infiltrations.     

Intrasellar pituitary schwannoma.

Schwannomas are common in the central nervous system, but only a few cases in the pituitary fossa have been reported. Described here is a case of an intrasellar schwannoma associated with headaches and behavioural changes, which responded to subtotal excision of the lesion. The diagnosis of intrasellar schwannoma was made on the basis of a constellation of microscopic findings, especially histologic features and immunohistochemical markers. The clinical and laboratory presentation, surgical procedure used and microscopic findings are compared with those in the literature.     

Pituitary abscess

A 28-year-old Caucasian woman presented with a 12 month history of secondary amenorrhoea, polyuria and polydipsia with fatigue and weight loss. Investigations revealed panhypopituitarism, diabetes insipidus, an intrasellar mass and papilloedema, thought to be due to benign intracranial hypertension. She was treated conservatively. However, a repeat magnetic resonance image showed enlargement of the pituitary mass with compression of the optic nerves. The pituitary abscess was drained by a transsphenoidal approach. Postoperatively the patient received antibiotics with no recurrence of the pituitary abscess.     

Rathke's cleft cyst presenting as pituitary apoplexy.

Sellar lesions mainly constitute pituitary adenomas, craniopharyngiomas and benign cysts. Rathke's pouch cyst is a developmental sellar and/or suprasellar cystic lesion lined by a single layer of ciliated cuboidal or columnar epithelium, which rarely be comes symptomatic. The authors present an interesting case of intrasellar Rathke's pouch cyst, with a presenting feature of acute pituitary apoplexy. This was a 19 year old healthy male who had developed sudden headache and visual disturbance. Neuro-radiological imaging revealed a mass in the sella. Via transsphenoidal approach a haemorrhagic intrasellar cystic lesion was removed and was confirmed as a haemorrhagic Rathke's cleft cyst by histopathological examination. Interesting clinical presentations and the neuroimaging findings are described and discussed.     

垂体脓肿的诊断和经蝶显微手术治疗

目的探讨垂体脓肿的诊断及治疗方法。方法回顾性分析我院15例垂体脓肿患者的临床表现、影像学特征、诊断和治疗。结果15例患者中术前主要表现为头痛8例,视力下降或颞侧偏盲6例,垂体前叶功能低下7例,尿崩4例,发热1例。MRI增强示病灶均呈环形强化。15例患者均采用经鼻蝶手术入路清除脓肿。术后1W,8例头痛患者症状均消失,6例视力下降患者中4例改善;术后随访至第3个月,4例尿崩患者有2例恢复正常,7例垂体功能减退患者中4例好转,另3例患者继续予以药物替代治疗;术后6个月,另2例仍多饮多尿患者和3例垂体功能仍低下者均恢复正常。15例患者均无复发。结论垂体脓肿术前诊断较困难,对鞍区囊性病变应考虑到垂体脓肿的可能性。及早采用微创手术、合理应用抗生素及恰当的对症治疗是治疗垂体脓肿的关键。     

A case of Rathke's cleft cyst with apoplexy

We report a case of Rathke's cleft cyst associated with cholesterin granuloma in an 8-year-old girl with apoplexy. She was admitted to our hospital in April 1996 because of repeated headache and deep ophthalmic pain, without any visual disturbance. Computed tomography (CT) of the pituitary demonstrated an intrasellar isodense mass extending to the suprasellar cistern. Magnetic resonance imaging (MRI) showed a high-intensity mass on both T₁- and T₂-weighted images. The preoperative diagnosis of this lesion was Rathke's cleft cyst associated with a craniopharyngioma and/or hemorrhage. Transsphenoidal microsurgery was performed, and a bloody coffee-like serous and mucinous-yellowish substance was evacuated. Curettage of the wall removed the yellowish hard mass and soft membranous tissue. Histological examination of this tumor revealed a Rathke's cleft cyst with cholesterin granuloma. Received: 28 April 1997 Revised: 25 August 1997     

Hypopituitarism resulting from an intrasellar carotid aneurysm

We report a 74 year old lady who presented with an exceedingly rare combination of an internal carotid artery aneurysm which was almost entirely intrasellar and associated with hypopituitarism but no neurological deficits. Such a lesion could be misdiagnosed as a pituitary tumour with serious consequences, if surgery is attempted without prior carotid angiography.     

小脓肿型脑囊虫与脑内小脓肿的鉴别

目的:研究小脓肿型脑囊虫的临床、计算机体层摄影(CT)特点及与脑内小脓肿的鉴别。方法:采用回顾性研究手段,对10年间手术证实的14例小脓肿型脑囊虫和16例脑内小脓肿进行了对比分析。结果:小脓肿型脑囊虫病人无高颅压和神经功能缺失症状。而小脓肿病人有3例出现了高颅压或神经功能缺失症状。小脓肿型脑囊虫的CT表现为规则的环形强化灶,小于或等于15mm,灶周水肿较轻,脑室形态正常,中线结构无移位。而小脓肿多为不规则的环形强化灶,多数大于或等于10mm,灶周水肿明显,少数病人脑室受压变形,中线结构移位。结论:小脓肿型脑囊虫和脑内小脓肿的临床表现和CT特征有所不同,认识其特点有利于正确诊断和选择治疗方案。     

Intrasellar epidermoid cyst presenting as pituitary apoplexy

We herein present a patient with intrasellar epidermoid cyst presenting as pituitary apoplexy, who was operated upon with a trans-sphenoidal approach. The clinical presentation, radiological and histological differential diagnosis and type of surgical intervention for intrasellar epidermoid cysts are discussed.     

Chronic lymphocytic leukemia presenting as a pituitary mass lesion.

We describe a unique case of chronic lymphocytic leukemia (CLL) in a patient who presented with bitemporal hemianopsia, adrenal insufficiency, and gonadotrophin deficiency. Studies revealed an enhancing intrasellar mass with suprasellar extension and displacement of the optic chiasm. Peripheral blood and cerebrospinal fluid (CSF) studies disclosed a monoclonal IgM kappa expressing B-cell CLL. Biopsy of the pituitary mass revealed dense infiltration of the pituitary gland by leukemic cells. This is, to our knowledge, the first reported case of CLL presenting as a pituitary mass lesion.