Case Report Batam

8/2/2019 Case Report Batam

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CASE REPORT : INVASIVE PITUITARY MACROADENOMASianny Suryawati 1, Aaron Manullang 1, Benny Huwae 2

1. Radiology Resident, Airlangga University – DR. Soetomo Teaching Hospital Surabaya2. Professor, Neuroradiology Consultant, Airlangga University – Soetomo Teaching Hospital

IntroductionA pituitary macroadenoma is a benign growth larger than 10 mm. It is the most common cause of a

mass in the sella, accounting for up to 10 – 15% of intracranial neoplasms and have an annual incidence inthe general population of about 25 per million. Six percent to 10% of pituitary adenomas involve thecavernous sinus and are considered to be invasive. Cavernous sinus invasion corresponds to biologicallyaggressive neoplasms and increases the morbidity and mortality associated with surgical procedures, evenif the tumor remains histologically benign in most of the cases.

CaseA 30 years old male admitted to dr. Soetomo Hospital with right side headche which worsen in two

years accompanied with right opthalmoplegia. He also complains nausea and projectile vomiting since ayear ago, several episodes of convulsion started 8 months ago, and right eye diplopia since 7 monthsago.Neurologic examination performed in this patients revealed cranial nerves involvement, include rightanosmia, right eye blindness with decerased visus of left eye, anisokhoria, slight facial palsy of right sideand right hypogeusia, left lingual palsy central type and hearing impairment of right ear.

Imaging FindingMSCT scan performed to this patient revealed a solid intrasellar mass sized 3.42x3.54x5.01 cm

with significant right lateral and superior extra-sellar extension. The mass showed heterogenous contrastenhancement and figure of eight appearance. The mass compresses the anterior horn of right lateralventicle and causing midline shift to the left side. There is widening of the sella and the sellar floor isthinning with bony erosion of lateral wall. No extension to the sphenoid sinus nor nasopharynx.

Discussion

Macroadenoma, which account for 70-80% of adenomas, are seen most commonly in between theages of 25 and 60 years. It is usually endocrinologically inactive and present with clinical symptoms of mass effect or resulting hypofunction of the gland. Clinical importance is its relation to the opticalpathways, pituitary apoplexy, hydrocephalus and cranial nerve involvement.

Invasive adenomas extend beyond the pituitary capsule, perforate the dura, and invade bone,cranial nerves, blood vessels, venous sinuses, and brain. Cavernous sinus invasion renders the surgicalprocedure more difficult and less efficient, therefore its preoperative diagnosis has to be as precise aspossible. Because there are no lateral bone boundaries to the pituitary fossa, the expansions developmainly in these lateral directions, and 6% – 10% of pituitary adenomas involve the cavernous sinus. Cottieret all proposed these criteria to diagnose the cavernous sinus invasion : it was suspected of being invadedif one of these two signs was absent (a normal pituitary gland and/or medial venous group between theadenoma and the intracavernous ICA was seen on each of the coronal sections) and the following features

are seen : (1) Total encasement of the intracavernous ICA (2) Displacement of the intracavernous ICA bythe tumor. (3) Asymmetry of the right and left cavernous sinuses. (4) Nondepiction of the lateral,superior, inferolateral, and carotid sulcus venous compartments. (5) Lateral bulging of the lateral duralwall of the cavernous sinus (6) Nondepiction of the medial dural wall of the cavernous sinus. (7)Whether the tumor crossed one of the intercarotid lines, joining the lateral walls (lateral line), center(median line), and medial walls of the intracavernous and supracavernous portions of the ICA.

Treatment of pituitary adenomas consists of surgical removal, observation and/ or adjunctivemedical therapy, and radiotherapy.







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Case Report Batam