Case of the Month: June 2016

What you see, isn’t always what you get: Visual impairment by (peri-)sellar lesion

by S De Vleeschouwer (1), J Verhoeven (1), P Demaerel (2), and R Sciot (3)

(1) Dept Neurosurgery, University Hospitals Leuven, Belgium
(2) Dept Radiology, University Hospitals Leuven, Belgium
(3) Dept Pathology, University Hospitals Leuven, Belgium

Case presentation

A 77-year old woman was referred to our center by her ophthalmologist. Four years ago, she was diagnosed with normotensive glaucoma of the left eye (1). Four months later, also the right eye got involved. After three years, topical treatment became insufficient so she received a trabeculectomy. Symptoms of diplopia developed shortly after this procedure. In addition, visual impairment didn’t improve after oftalmologic treatment. In her medical history, a rectal adenocarcinoma had been treated 7 year ago with curative intent.

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* 1. Differential diagnosis (2)? (Please select all that apply)

Iatrogenic, postoperative, trauma

Stroke, hemorrhage

Intracranial mass lesion

Thrombosis of the cavernous sinus

Ocular myositis

Myasthenia gravis

Inflammation

Toxins (lead, alcohol)

Other (please specify)

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* 2. Physical examination shows bitemporal hemianopsia. How does this alter your differential diagnosis?

Intracranial mass lesion: pituitary adenoma, craniopharyngeoma, meningioma,

Vascular disorder: aneurysm

Other (please specify)

MRI showed an intracranial mass lesion of the sellar tubercle and diaphragm. Please see Figures 1 - 4.

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Figure 1 Sagittal T1 image with Gadolinium enhancement

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Figure 2 Coronal T1 image with Gadolinium enhancement

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Figure 3 Axial T1 image with Gadolinium enhancement

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Figure 4 T2 image depicting the (minor) cystic component of the lesion

The lesion showed a clear dural tail on sagittal images, a meningioma was therefore suspected. However, due to the extent of sellar expansion the possibility of a pituitary adenoma was also considered. The posterior part of the lesion had a partially cystic aspect.

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* 1. Differential diagnosis (2)? (Please select all that apply)

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* 2. Physical examination shows bitemporal hemianopsia. How does this alter your differential diagnosis?

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Figure 1 Sagittal T1 image with Gadolinium enhancement

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Figure 2 Coronal T1 image with Gadolinium enhancement

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Figure 3 Axial T1 image with Gadolinium enhancement

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Figure 4 T2 image depicting the (minor) cystic component of the lesion

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* 3. How could you interpret the posterior cystic component of the lesion in case of a meningioma?