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

Abscess formation within a Rathkes’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.

1351 Primary Pituitary Abscess Presenting as An Isolated Bitemporal Hemianopia

Pituitary abscesses are rare yet life-threatening entities. Most common presenting features are headache, hypopituitarism, and visual changes. Majority of patients are found to have a predisposing risk factor, such as a pre-existing pituitary lesion, recent pituitary surgery or irradiation, or a primary source of infection. We present the case of a 53-year-old male with a spontaneous pituitary abscess, who presented with an isolated bitemporal hemianopia, but was otherwise asymptomatic with no known risk factors. Magnetic resonance imaging showed a sellar and suprasellar mass, thought to be a pituitary macroadenoma. He underwent endoscopic transsphenoidal adenectomy and cystic fluid was seen intraoperatively. Microbiology analysis showed Staphylococcus Aureus, and a course of intravenous ceftriaxone was commenced. Histopathology reported no evidence of adenoma and impression was of a pituitary abscess. Following transsphenoidal resection and commencement of antibiotic therapy, the bitemporal hemianopia resolved. We therefore report a rare case of primary pituitary abscess and emphasise the importance of including this condition as a differential diagnosis in any patient with a visual deficit or new pituitary lesion.

Endoscopic Endonasal Excision of an Optic Pathway Cavernous Malformation: Technical Case Report

BACKGROUND AND IMPORTANCE Cavernous malformations (CMs) are angiographically occult low-flow vascular malformations that infrequently involve the optic pathway and the hypothalamus (OPH). CLINICAL PRESENTATION A 23-yr-old male presented with bitemporal hemianopia due to chaismal apoplexy. Imaging revealed a CM involving the OPH. The CM was resected by an extended endonasal approach. The patient had improvement in his visual field defects, and postoperative magnetic resonance imaging (MRI) revealed a gross total resection of the CM. CONCLUSION This case demonstrates the surgical technique of endoscopic endonasal resection of a CM involving the optic pathway.

A STUDY OF CLINICAL PRESENTATION AND MANAGEMENT OF PITUITARY TUMORS

The study includes 25 cases of pituitary adenomas. Most common age group by pituitary tumors falls between 41-50 years of age. Male: Female incidence of these tumors is 1: 2.12. Most common clinical symptoms in our series are visual disturbances followed by headache. Optic nerve involvement is other common clinical nding presenting in form of decreased vision or loss of vision, eld defect or fundus changes. Commonest eld defect is bitemporal hemianopia. MRI is the diagnostic investigation of choice in pituitary tumors to dene extent, invasion and relationship to major vessels and nerves. Approximately half (44%) of the patients exhibited normal preoperative pituitary function in form of baseline hormone prole. Increased GH level (32%) followed by hyperprolactinemia (20%) are the most common endocrinologic abnormalities. Total/near total removal was done in 21 patients (84%) and subtotal removal done in 4 patients (16%). Adjuvant therapies were given in 5 patients. Two patients were given radiotherapy and 3 were given pharmacotherapy. Post operative complications were CSF leak, diabetes insipidus and meningitis. 20 patients (80%) had improvement in their symptoms including relief from headache, improvement in vision and endocrinal dysfunction. Post operatively visual functions improved in 13 patients (52%) and it remained stationary in 11 (44%) patients. Only one patient (4%) complained of worsening of his visual function and it was improved in follow up period

Isolated bitemporal hemianopia in a patient with COVID-19

Introduction. Symptoms of lesions of the I, VII and IX pairs of cranial nerves during SARS-CoV-2 infection are observed in about a third of cases. Isolated bitemporal hemianopia as a symptom of optic nerve damage at the chiasmal level in patients with COVID-19 has not been described yet. Case report. A 65-year-old man with a history of arterial hypertension and myocardial infarction and confirmed COVID-19 infection with severe lung damage on computed tomography. Patient developed bitemporal hemianopia, confirmed by the Donders test, on the second day of hospitalization. CT scan revealed no lesions and organic pathology in the parachiasmatic region and in the substance of the brain. Two days later, there was a complete restoration of lateral vision. Discussion. The most likely cause of bitemporal hemianopia was microthrombotic or inflammatory lesion at the chiasmal level. Risk factors for thrombotic complications: male gender, age 65, history of cardiovascular diseases, increased D-dimer levels, and signs of systemic inflammation (increased levels of C-reactive protein, fibrinogen, lactate dehydrogenase, and ferritin). An alternative hypothesis for the development of chiasmal syndrome may be direct viral invasion SARS-CoV-2 of the central nervous system.

Pituitary hyperplasia causing complete bitemporal hemianopia with resolution following surgical decompression: case report

In this report, the authors demonstrated that idiopathic pituitary hyperplasia (PH) can cause complete bitemporal hemianopia and amenorrhea, even in the setting of mild anatomical compression of the optic chiasm and normal pituitary function. Furthermore, complete resolution of symptoms can be achieved with surgical decompression.PH can occur in the setting of pregnancy or end-organ insufficiency, as well as with medications such as oral contraceptives and antipsychotics, or it can be idiopathic. It is often found incidentally, and surgical intervention is usually unnecessary, as the disorder rarely progresses and can be managed by treating the underlying etiology. Here, the authors present the case of a 24-year-old woman with no significant prior medical history, who presented with bitemporal hemianopia and amenorrhea. Imaging revealed an enlarged pituitary gland that was contacting, but not compressing, the optic chiasm, and pituitary hormone tests were all within normal limits. The patient underwent surgical decompression of the sella turcica and exploration of the gland through an endoscopic endonasal transsphenoidal approach. Pathology results demonstrated PH. A postoperative visual field examination revealed complete resolution of the bitemporal hemianopia, and menstruation resumed 3 days later. The patient remains asymptomatic with no hormonal deficits.

MON-LB49 Atypical Presentation for a 5.5-cm Macroprolactinoma: Unilateral Visual Loss and Only Partial Hypopituitarism; Asymptomatic Hypogonadism

Background: Macroprolactinoma is an uncommon pituitary tumor which presents mainly in males. The usual presentation is headache, bitemporal hemianopia, and signs/symptoms of hypogonadism. Ours is a case report of 5.5 –cm macroprolactinoma presented with unilateral optic nerve atrophy and asymptomatic hypogonadism. Clinical case: A 50-year-old male with past medical history of type 2 diabetes mellitus and essential hypertension presented with progressive blurred vision of the left eye for 6 months. He was able to perceive color but had difficulty reading. There was occasional headache with left periorbital pain. He was seen by an optometrist and was found to have left optic disc atrophy with suspicion of glaucoma. Subsequent visual field test showed entire left and right superior temporal loss. MRI of the pituitary showed 5.5 x 5.6 x 5.3 cm enhancing mass centered in the sellar/suprasellar region. There was significant mass effect with compression of the optic chiasm, temporal lobe and brainstem. The patient reported mood changes, normal libido, but loss of morning erection. He has family history of pituitary macroadenoma with left optic nerve compression. On physical examination, there were left visual field defect and decreased visual acuity. There were no signs of Cushing’s syndrome, hypothyroidism, acromegaly, or hypogonadism. Laboratory tests showed prolactin of >200 ng/ml and 16,610 ng/ml after dilution (male <13), total testosterone 92 ng/dl (240-950) and free testosterone 1.20 mg/dl (4.26-16.40). Surprisingly, other pituitary hormones were normal: AM cortisol 20.3 µg/dl (6-27), GH 0.24 ng/ml (0.01-0.97), IGF-1 58 ng/ml (40-259), FSH 4 IU/l (1-18), LH 3 IU/l (1.3-9.6), TSH 1.38 µIU/ml (0.34-3), and free T4 0.8 ng/dl (0.6-1.6). The patient underwent surgery with partial resection. Pathology revealed lactotroph adenoma. Postoperative prolactin level was 11,900 ng/ml. Medical treatment with cabergoline 0.25 mg twice weekly has been started. Conclusion: Even though profoundly hypogonadal by labs, the presentation for this 5.5-cm prolactinoma was acute vision loss. The highly elevated prolactin level correlates with the size of macroadenoma. The typical presentation of local mass effect is bitemporal hemianopia, but in our case the patient presented with unilateral optic nerve atrophy. Despite a 5.5-cm lesion, there is partial hypopituitarism; hypogonadism. Based on the size, one would have expected panhypopituitarism. Given a family history of macroadenoma, there might be genetic predisposition. Molecular testing is planned.

SAT-275 Bitemporal Hemianopia as a Result of Cabergoline Therapy for Macroprolactinoma

Background: Cabergoline is first-line treatment for prolactin-secreting pituitary macroadenoma (prolactinoma). Side effects such as nausea, valvulopathy and neuropsychiatric symptoms are well recognized complications of its use. A rare complication is vision loss secondary to empty-sella syndrome. Clinical case: A 27-years old women was diagnosed in 2009 with macroprolactinoma with a prolactin level of 2,523.91ng/mL (normal 3.3-26.7ng/mL), during work up of frontal headaches, amenorrhea and infertility. The rest of her pituitary work up was normal. She was started on dopamine receptor agonist therapy with Cabergoline 0.25mg two times a week. Her headaches improved within a few month. The prolactin level normalized and MRI at 1 year after starting Cabergoline therapy showed significant decrease in pituitary adenoma to 3mm. She continued Cabergoline therapy for 3 years, after which time it was discontinued. For the next 6-8 years she was on and off Cabergoline therapy for mild elevation of prolactin and galactorrhea/headache symptoms, with improvement of symptoms on Cabergoline. However, nine years after diagnosis and Cabergoline treatment, she developed vision loss, characterized by bitemporal hemianopia. MRI showed partial empty sella with downward displacement of the optic chiasm. Cabergoline therapy was stopped with some improvement of visual symptoms on exam. Here latest prolactin level is at 134ng/ml. Surgical management with chiasmapexy is being explored. Conclusion: Vision loss secondary to optic nerve traction from chiasmal herniation in the setting of an empty sella can be a consequence of Cabergoline therapy. No predictors or risk factors are known for the development of this complication. Furthermore, no clear evidence is available of benefit from discontinuation/continuation of therapy. Novel surgical management with chiasmapexy is being explored as a solution to stabilize the optic chiasm and resolve visual symptoms without further complications.