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Medical history and examination results
The patient is a middle-aged and elderly woman who complained of dizziness and blurred vision for 6 + months; Upon admission, the gross visual acuity of both eyes decreased, and the field of view in the right eye narrowed compared to the contralateral side (previously with congenital right eye strabismus and inward upward strabismus). Neurological specialist physical examination and other physical examinations show no other clinical symptoms or neurological dysfunction. The patient's cranial MRI plain scan and enhancement showed the presence of a cystic solid mass in the pituitary gland. After enhancement, uneven enhancement was observed internally, and cystic masses were present in the pituitary stalk, suprasellar cistern, and anterior part of the third ventricle. After enhancement, marginal enhancement was observed (due to the fact that the base is mainly located in the pituitary stalk, hereinafter referred to as the pituitary stalk mass), with compression near the optic chiasm (Fig. 1). General laboratory tests and pituitary related hormones show no significant abnormalities. The patient was diagnosed as follows: 1. Saddle area mass- Pituitary tumor? 2. Pituitary stalk mass: craniopharyngioma? Colloid cyst? After communicating with the patient, the patient chose to first treat the pituitary mass in the sella turcica and refused to explore the pituitary stalk area, and followed up to observe the pituitary stalk mass.
2. Surgery and postoperative process
During endoscopic transnasal transsphenoidal surgery, the tumor appears pink gray in color, with a soft texture and abundant blood supply. The intrasellar mass is completely removed. Postoperative pathology and immunohistochemical staining of pituitary related hormones confirmed non-functional pituitary adenoma. After the surgery, the patient developed transient diabetes insipidus, but after treatment with medication such as Desmopressin acetate tablet, the insipidus was quickly controlled without any special circumstances.
(A, B) Short T2-weighted and short T1-weighted sagittal MRI signal showing the masses in the saddle area and suprasellar area (arrows indicate the mass); (C) Coronal MRI showed the position relationship between the two masses; (D, E, F) Enhanced MRI images can clearly show the cystic mass in the suprasellar area and the solid cystic mass in the sellar region (E; arrow indicates the solid cystic mass in the sellar region. F; arrow indicates the cystic mass in the suprasellar area).
3. Inspection results
Four days after surgery, a follow-up cranial CT scan revealed a slight increase in density within the pituitary fossa, suggesting postoperative changes. The cystic mass of the pituitary stalk is still visible (Fig. 2). The patient recovered well after surgery without any clinical symptoms or signs. Due to personal reasons, regular follow-up and re examination were not conducted.
At 22 months after surgery, the patient came to the hospital for examination due to "unclear vision in the left eye for one month". The visual acuity test showed that the left eye had almost lost its ability to see far away, and the ability to see near sightedness had significantly decreased. Visual field examination showed that the left eye's field of view was narrower than that of the right eye, and the average sensitivity and average defect were significantly reduced compared to normal values. The visual acuity of the right eye was lower than the normal values in terms of average sensitivity and average defect, but significantly better than that of the left eye. Endocrine assessment showed an increase in PRL levels and a decrease in follicle stimulating hormone and luteinizing hormone levels. The levels of other pituitary related hormones are normal. The comparison between pituitary MRI and postoperative follow-up showed a significantly enlarged pituitary stalk mass with clearly defined cystic solid masses, and compression of the third ventricle, thalamus, and optic chiasm (Fig. 3). This diagnosis is a pituitary stalk mass: craniopharyngioma? Elevated prolactin considers the pituitary stalk effect.
4. Second surgery and postoperative treatment course
The patient underwent a second surgery, which involved total resection of pituitary stalk tumors through the interhemispheric longitudinal fissure approach. During the operation, the tumor was found to be located in the suprasellar cistern, with intact sellar diaphragm. Its root was emitted from the pituitary stalk and compressed against the optic chiasm, presenting as cystic solid. Some were soft with bleeding, while others were tough and had a grayish white color. 10 days after surgery, a follow-up MRI confirmed complete resection of the tumor (Fig. 4). Pathological examination revealed craniopharyngioma, characterized by multiple layers of squamous epithelium arranged in a trabecular pattern (Fig. 5). The patient's postoperative reexamination of endocrine hormones showed a comprehensive decrease in pituitary related hormone levels, and timely treatment with hydrocortisone, prednisone, and levothyroxine sodium tablet was given. The patient's condition stabilized and was discharged from the hospital. Eleven months later, follow-up MRI confirmed that the tumor did not recur (Fig. 6). Unfortunately, the patient's left eye vision did not recover.
(A, B) The short T2-weighted sagittal MRI and coronal MRI signal showing the mass in the saddle area and suprasellar area(arrows indicate the mass), the mass was significantly larger than before; (C, D) Enhanced MRI image showed that the mass density was not uniform, which was a solid cystic mass.
Postoperative enhanced MRI showed that the sellar and suprasellar regions were empty, and the mass was completely resected. (A; coronal T1-weighted enhanced MRI images. B; sagittal T1-weighted enhanced MRI images).