Thickening of the pituitary stalk: a finding suggestive of intrasellar tuberculoma? Case report

Pediatric sellar-suprasellar tuberculosis: A case report and review of the literature

Background

Pediatric sellar-suprasellar tuberculosis is a rare form of tuberculosis that affects the pituitary gland and surrounding areas in the brain. It can be difficult to diagnose based on clinical and radiological signs alone, as they can be similar to other pituitary masses. A combination of biological, hormonal, and imaging examinations can aid in making an accurate diagnosis. It is important to consider tuberculosis in the differential diagnosis of sellar-suprasellar masses in the pediatric population, especially in areas with a high prevalence of tuberculosis.

Case Description

A 17-year-old male with no history of illness showed up with a series of symptoms, including headaches and vision problems. A sellar-suprasellar lesion was seen on imaging, along with several minor lesions. The diagnosis of tuberculosis meningitis with cerebral and pituitary tuberculoma was made after cerebrospinal fluid analysis revealed the presence of tuberculosis. Treatment with anti-tuberculosis drugs led to clinical improvement and lesion resolution.

Conclusion

Children's sellar tuberculomas can be difficult to diagnose since they resemble other pituitary tumors. It is essential to take them into account in the differential diagnosis, especially in regions with a high incidence of tuberculosis. Long-term chemotherapy is the recommended course of treatment, and monthly follow-up visits are necessary to check hormone levels and evaluate whether a permanent hormone replacement is necessary.

Primary pituitary tuberculosis

Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

Tuberculosis: A Common Infection with Rare Presentation, Isolated Sellar Tuberculoma with Panhypopituitarism

Isolated sellar tuberculoma is a very rare condition and usually presents with headache and decreased vision. It can present with panhypopituitarism with 3^rd nerve palsy. Tuberculoma mimics pituitary adenoma clinically as well as radiologically and requires endoscopic transsphenoidal surgery and histopathological examination for the final diagnosis. We present a rare case of a 40-year-old female presented with headache, decreased vision, and unilateral 3^rd nerve palsy with panhypopituitarism.

Primary Pituitary Tuberculosis Revisited

Patient: Female, 45

Final Diagnosis: Primary pituitary tuberculosis

Symptoms: Headache • vomiting • vomiting

Medication: —

Clinical Procedure: Pituitary biospy

Specialty: Endocrinology and Metabolic

Reversible hypopituitarism with pituitary tuberculoma

A 50-year-old woman presented with a headache and nausea. A sellar and suprasellar mass was detected on MRI; the tumor was heterogeneously enhanced with gadolinium, and the pituitary stalk was slightly thickened. Laboratory tests revealed severe growth hormone, luteinizing hormone, follicle-stimulating hormone and thyroid-stimulating hormone deficiencies. A pathological examination of the tumor showed scattered granulomas with central necrosis and Langhans giant cells. Tuberculin skin and QuantiFERON TB-Gold tests (QFT-2G) were positive. Accordingly, we diagnosed the patient with pituitary tuberculoma presenting with pituitary dysfunction. Following treatment with antituberculous drugs, the pituitary hormone function normalized and the pituitary tuberculoma disappeared.

Surgical biopsies in patients with central diabetes insipidus and thickened pituitary stalks

Thickened pituitary stalks (TPSs) on magnetic resonance imaging (MRI) result from diverse pathologies; therefore, it is essential to make specific diagnoses for clinical decision-making. The diagnoses and indications for surgical biopsies in patients with central diabetes insipidus (CDI) and TPSs are thoroughly discussed in this paper. Thirty-seven patients with CDI and TPSs were retrospectively reviewed. The mean age at the diagnosis of CDI was 29.0 ± 15.9 years (range 8.0-63.3), and the median duration of follow-up was 5.5 ± 2.8 years (range 0.7-13.0). Anterior pituitary hormone deficiencies were documented in 26 (70.3 %) patients. All patients had a TPS on MRI at the diagnosis of CDI, and 21 (56.8 %) patients exhibited radiological changes during the follow-up. Of these 21 patients, 11 exhibited increases in the thickness of the stalk, and two patients exhibited reversals of the TPSs. Involvements of the hypothalamus, pituitary gland, basal ganglia or supersellar, and pineal gland were found in four, three, one, and 1 patient, respectively. Ultimately, clear diagnoses were established in 17 patients who underwent biopsies, nine of whom had germinomas, six of whom had Langerhans cell histiocytosis, one of whom had a granular cell tumor, and one of whom had Erdheim-Chester disease. Patients with CDI and TPSs should submit to periodic clinic follow-ups with serial MRI assessments to establish anterior pituitary deficiencies and to detect radiological progressions that are appropriate for surgical biopsies. Endoscopic-assisted microsurgery via the supraorbital keyhole approach is a good choice for the biopsy of pituitary stalk lesions.

Clinical presentation and magnetic resonance findings in sellar tuberculomas

Background and Importance. Sellar tuberculomas are extremely rare lesions with nonspecific clinical manifestations. The tuberculous infection of the pituitary gland and sellar region is characterized by the presence of an acute or chronic inflammatory reaction and may occur in the absence of systemic tuberculosis. The diagnosis is difficult prior to the surgery. An adequate diagnostic and antituberculous drugs usually result in a good outcome. Clinical Presentation. We report four cases of sellar tuberculoma, 3/1 female/male, age range: 50–57 years. All patients had visual disturbances and low levels of cortisol. Conclusion. The clinical diagnosis of sellar tuberculoma is a challenge and should be suspected when a sellar lesion shows abnormal enhancement pattern and stalk involvement, and absence of signal suppression in FLAIR.

Tuberculoma of the Cavernous Sinus and Meckel's Cave in a Child

Tuberculous infection of the cavernous sinus and Meckel's cave is extremely rare. In this report, we describe a patient with tuberculoma of the cavernous sinus and Meckel's cave, extending to the petrous apex. The patient underwent microsurgical excision of the lesion and antitubercular chemotherapy resulting in a good outcome. We describe the diagnostic difficulties and review the relevant literature.

Central diabetes insipidus as the inaugural manifestation of Langerhans cell histiocytosis: natural history and medical evaluation of 26 children and adolescents

CONTEXT

Isolated central diabetes insipidus (CDI) can be the first manifestation of Langerhans cell histiocytosis (LCH), creating diagnostic dilemmas such as dysgerminoma and other inflammatory lesions.

METHOD

In 2010, the French national LCH registry had enrolled 1236 LCH patients under 18 yr of age. Isolated CDI was the initial presentation of LCH in 26 patients. We reviewed their clinical and magnetic resonance imaging (MRI) features.

RESULTS

Median age at the diagnosis of CDI was 9.6 yr (1.8-16.3), and median follow-up after CDI diagnosis was 9.9 yr (3.5-26.6). In addition to CDI, two patients had visual field defects, four had secondary amenorrhea, and 11 had anterior pituitary deficiency. Cerebral imaging (including computed tomography in two cases), performed in 22 patients within 3 months of CDI diagnosis, showed pituitary stalk thickening in 14 patients, which was moderate (3.0-7 mm) in nine cases and marked (>7 mm) in five cases. In eight cases, the lesion extended to the floor of the third ventricle. One child with LCH presented with a mild enlarged sellar content. During follow-up, 22 patients developed extrapituitary involvement, mainly of bone (n = 15), lung (n = 9), and skin (n = 9). Pituitary biopsy was performed in eight cases and was conclusive in six cases.

CONCLUSIONS

Pituitary stalk thickening can be observed in LCH as well as lesions extending to the floor of the third ventricle. In all cases but one, the intrasellar content was not enlarged. Long-term follow-up with close attention to bone, skin, and lung disorders may lead to the diagnosis of LCH.

[Isolated hypophyseal tuberculoma: often mistaken]

Hypophyseal tuberculoma is extremely rare and difficult to diagnose without a clearly suggestive context. Its radiologic features are not specific and are better recognized on MRI with a mass of a variable signal related to the percentage of caseous necrosis. A frequently associated thickening of the pituitary stalk suggests tuberculosis, requiring the search for another tuberculosis location. This paper reports an original case of hypophyseal tuberculoma since it occurred with no other tubercular infection, which delayed the diagnosis despite thickening of the pituitary stalk on MRI.

Pituitary tuberculosis mimicking idiopathic granulomatous hypophysitis

An unusual case of tubercular granulomatous hypophysitis is reported. A sellar mass diagnosed as pituitary adenoma in MRI, showed non-caseating granulomas, glandular destruction and fibrosis in histology. Stain for acid-fast bacilli (AFB) were negative and the case was misdiagnosed as Idiopathic Granulomatous hypophysitis. The patient came back 2 weeks after trans-sphenoidal endoscopic resection with meningitis. CSF showed mixed pleocytosis. PCR for Mycobacterium tuberculosis was positive. The case is reported to highlight the need to maintain a high degree of suspicion for tuberculosis in any form of granulomatous hypophysitis, with or without caseous necrosis, in regions endemic for tuberculosis to prevent subsequent complications.

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.

[Pituitary tuberculosis: a case report]

Through a case of sellar and suprasellar tuberculoma which presented with central diabetes insipidus, the authors report the frequency of pituitary tuberculoma, its physiopathology, clinical presentation hormonal and radiological findings thus management and evolution. A 42 years old woman, with a history of erythema nodosum, presented with polyuria polydipsia (PUPD), amenorrhea and galactorrhea. Endocrine investigations showed central diabetes insipidus, elevated serum prolactin levels and cortisol failure. Magnetic resonance imagining scans (MRI) revealed a nodular thickening of the pituitary enlargement and loss of posterior pituitary hypointensity signal. Etiologic inquiry has removed the diagnosis of sarcoidosis, Langerhan's histosis, autoimmune hypophysitis and sellar metastasis. The history of erythema nodosum, the positivity of tuberculin skin test and the presence of koch bacillus in the bronchial fluid after culture led to a diagnosis of tuberculosis. Treatment was started with four drug antitubercular chemotherapy regimen for 2 months, and tow drug antitubercular chemotherapy regimen for 16 months. This treatment is associated with hydrocortisone, desmopressin nasal spray and bromocriptine. Under treatment, there was an improvement in clinical condition, disapearence of headache, PUPD and galactorrhea thus normalization of prolactin. A follow-up MRI, 8 months later, showed that pituitary lesion has been completely removed, suggesting our clinical and biology presumption. Pituitary tuberculosis is rare, however, when encountered, they may present a diagnostic difficulty. Accurate diagnosis and management is important because pituitary tuberculoma is curable.

Suprasellar tubercular abscess presenting as panhypopituitarism: a common lesion in an uncommon site with a brief review of literature

Following widespread use of imaging, detection rate of abnormal sites of parenchymal neuro-tuberculosis is on a rise. A handful of cases of tuberculomas/abscesses in hypothalamo-pituitary region have been reported and most of them are diagnosed on surgical histopathology. We describe a patient of suprasellar tubercular abscess, who presented with visual disturbances, diabetes insipidus with panhypopituitarism and on histopathology had granulomas and positive acid fast bacilli.

Caseous Necrotic Granuloma in the Pituitary Stalk Due to Nontuberculous Mycobacteria (Mycobacterium Tokaiense) Infection-Case Report-

A 36-year-old man with no history of immunosuppression presented with diabetes insipidus, but no other hormonal disturbances. Magnetic resonance imaging of the brain revealed an enhanced mass in the pituitary stalk appearing as a thickened pituitary stalk. The mass lesion was completely removed through the right optico-carotid space. Histological examination showed epithelioid cell granuloma with caseous necrosis, which strongly suggested mycobacterial infection. However, acid-fast staining detected no bacteria. Polymerase chain reaction (PCR) examinations of the gastric juice and cerebrospinal fluid for tuberculosis were negative. Nested PCR and deoxyribonucleic acid (DNA) sequencing of the DNA from the surgical specimen disclosed Mycobacterium tokaiense DNA sequences. This rare case of pituitary stalk granuloma caused by M. tokaiense shows that if the surgical specimen contains caseous necrosis, nested PCR and DNA sequencing are useful methods to identify mycobacterial infection.

Pituitary abscess in a patient with painless thyroiditis

The preoperative diagnosis of pituitary abscess is difficult. The case of a 56-year-old man with a pituitary abscess and painless thyroiditis is presented. There has been no previous such report. The differential diagnosis includes pituitary abscess, lymphocytic adenohypophysitis or infundibuloneurohypophysitis, share clinical symptoms of panhypopituitarism and diabetes insipidus, and is of critical importance as the treatment of these conditions differ. The association with painless thyroiditis suggests a diagnosis of lymphocytic adenohypophysitis or infundibuloneurohypophysitis. However, the coincidence of pituitary abscess and painless thyroiditis was observed in our patient, and thus though rare, should be considered. Surgical exploration and histopathological examination are essential for the differential diagnosis of these diseases.

Imaging features of intrasellar tuberculoma: two cases

Hypophyseal tuberculoma is extremely rare. It may be confused with other more common sellar tumors such as adenomas. Characteristic, but not specific, radiological features are in the majority of cases: intense enhancement on contrast CT and thickening of the pituitary stalk better visible on MRI. We describe imaging findings in two patients with pituitary tuberculosis. In these cases an accurate non-invasive diagnosis was found to be important as antituberculous chemotherapy is curative.

An unusual association of acromegaly and pituitary tuberculosis

A young woman with acromegaly and disseminated tuberculosis involving pituitary is reported. She presented with classical features of acromegaly and was found to have retrocrural and retroperitoneal lymphadenopathy. Such association is quite rare.

Optic pathways tuberculoma mimicking glioma: case report

BACKGROUND

Optochiasmatic tuberculomas are very rare lesions. They can occur with concomitant tuberculous meningitis, and pulmonary tuberculosis or as the only manifestation of the disease. The authors present a case of optic pathways tuberculoma with radiologic appearance simulating an optic pathways glioma.

CASE DESCRIPTION

We report a case of a 20-year-old man with mental retardation due to anoxic encephalopathy who developed a sudden bilateral amaurosis. He also presented with diabetes insipidus, panhypopituitarism, right proptosis, and chemosis. Computed tomography (CT) and magnetic resonance imaging (MRI) showed an enhancing lesion in the optochiasmatic region extending to both optic nerves, with a mass in the right orbit, mimicking an optic pathways glioma. There was no other evidence of systemic involvement of the tuberculosis. The lesion was explored through a right pterional transylvian approach with opening of the optic canal and orbital roof, and a biopsy and an internal decompression were performed. Histopathological studies demonstrated a granulomatous lesion with central caseous necrosis with acid-fast bacilli. The patient improved after treatment with tuberculostatic drugs, but vision recovery could not be achieved.

CONCLUSIONS

Visual compromise in tuberculosis is associated with hydrocephalus, optical neuritis or tuberculomas involving the optic pathways. Reviewing the literature on tuberculomas of the optochiasmatic area, we could not find any other case with such extensive involvement of the optic pathways that was radiologically suggestive of an infiltrating glioma. Histopathological studies remain crucial in the diagnosis of intrinsic expansive processes of the optochiasmatic region.

Tuberculomas of the hypophysis cerebri: report of five cases

Tuberculomas involving the hypophysis cerebri are extremely rare lesions, and these may occur even in the absence of systemic tuberculosis. This report presents the clinical data of 5 patients harbouring tuberculomas of the pituitary gland. Sellar tuberculomas commonly mimic pituitary adenoma. Histological diagnosis of a sellar lesion is mandatory irrespective of the clinical presentation and radiological findings. A history of extracranial tuberculosis in the past associated with radiological findings like leptomeningeal enhancement, parenchymatous brain tuberculomas or a thickened pituitary stalk on contrast MRI, are indicative of the possibility of a sellar tuberculoma. The aim of surgery is tissue diagnosis and tumour debulking. The response to long-term antituberculous chemotherapy is excellent. There is often a complete resolution of the granuloma and a satisfactory recovery of visual and endocrinological function.

Solitary tuberculoma of the cerebellopontine angle: a rare presentation

Central nervous system tuberculoma presenting as a solitary mass in an extrinsic location is rare. Due to the increase in incidence of tuberculosis in the western world, there is a corresponding increase in CNS tuberculosis. Cerebellopontine angle tumours are most commonly acoustic schwannomas or meningiomas. Radiosurgery as a primary modality of treatment for many CNS masses without prior pathological diagnosis is increasing in popularity. This report shows that a mass in the CP angle can closely mimic a tumour radiologically and inappropriate radiation treatment was avoided after surgery. Histopathological examination proved it to be a tuberculoma. Awareness of this rare presentation of a solitary tuberculoma in the CP angle is emphasised.

Intraventricular tuberculoma

A 38-year-old female presented with headaches, fever, and malaise. Computed tomography showed an intraventricular peripheral ring-enhanced lesion with central necrosis. The lesion was totally excised. Histological examination revealed a tuberculoma. The patient was treated with antituberculous chemotherapy. The patient was asymptomatic at 9 months. Ventricular involvement in neurotuberculosis is rare, but should be considered in the presence of other indicators of tuberculous infection.

Pituitary tuberculoma: an unusual lesion of sellar region

Pituitary tuberculomas are extremely rare lesions, with only few cases described in the literature, usually mistaken as pituitary tumors. Its heterogeneous clinical and imaging profile preclude preoperative diagnosis which ultimately relies on the histopathological examination. We describe a 46 years old woman who presented with an episode of confusion and hypopituitarism with no evidence of systemic tuberculosis. Computed tomography (CT) showed a central calcified and enhancing sellar mass. Magnetic resonance imaging (MRI) showed a sellar mass with suprasellar extension and associated optic chiasm compression. She was submitted a craniotomy for biopsy and resection. A caseous material was found at the center of the lesion involved by a thick wall. Due to the wall adherence to the optic chiasm and the inflammatory aspects of the lesion, subtotal removal was achieved and the patient followed on anti-tuberculous and hormonal replacement therapy. Sellar tuberculomas should be considered in the differential diagnosis of sellar tumors in order to offer appropriate treatment.

Pituitary stalk tuberculoma

Pituitary tuberculomas are exceptionally rare. Even with no evidence of systemic tuberculosis, it is important to recognize these lesions in the differential diagnosis of the intrasuprasellar tumors because they are curable. At present, in developed countries the frequency of intracranial tuberculomas of nervous system tumors is around 0.5-4%, whereas in under developed countries is 15-30%. It mainly affects children and young adults. In some cases, an accurate diagnosis may lead to an efficient medical therapy on the basis of biological, hormonal and imaging scans examinations. The case we studied shows the difficulties encountered in the diagnosis of a thickened stalk having normal pituitary image. It is to be highlighted the usage of the Polymerase Chain Reaction (PCR) technique.

Pituitary tuberculoma mimicking adenoma: magnetic resonance imaging

A case of a pituitary mass with clinical and MRI findings consistent with adenoma is presented. Transnasal transphenoidal excision biopsy showed it to be a pituitary tuberculoma. The patient was treated with antituberculous drugs, and a follow-up MRI 18 months later showed good response. MRI features and a review of published reports of the sellar tuberculoma are briefly discussed.

Composite pituitary adenoma and intrasellar tuberculoma: report of a rare case

Tuberculous involvement of the pituitary gland is rare. We report a unique case of a composite lesion consisting of pituitary adenoma and intrasellar tuberculoma. A 24-year-old lady presented with features of acromegaly and amenorrhea. Serum growth hormone levels were found to be raised. Radiological investigations were consistent with a pituitary adenoma. Decompression of the lesion was done through trans-sphenoidal approach. Histological examination revealed a growth hormone secreting pituitary adenoma in association with a granulomatous lesion suggesting of pituitary tuberculoma. No other evidence of tuberculosis was found in the brain or spinal cord. This type of dual pathology has been reported only once in the earlier literature.

Intrasellar tuberculoma--an enigmatic pituitary infection: a series of 18 cases

OBJECTIVE

Intrasellar tuberculomas are rare and only few case reports have been described in the literature. We report a series of 18 cases of histologically proven intrasellar tuberculomas, which, to the best of our knowledge, is the largest series in the English literature.

METHODS

A total of 1143 pituitary lesions, between 1984 and June 1999, were operated for various reasons in our institute. Of these, 18 cases were histopathologically proven intrasellar tuberculomas. The clinical profile was reviewed in detail. Radiological data and histopathological slides were also reviewed.

RESULTS

The age ranged from 8 to 43 years (average 23.6 years) with a female preponderance. The duration of symptoms varied from 15 days to 2 years (average 4 months), the most common symptoms being headache followed by decrease or loss of vision. Five patients had features of pan-hypopituitarism whereas three had raised prolactin (PRL) levels. In six patients, both sella as well as sphenoid sinus were involved. In one patient the lesion was extending from the sella over the clivus. Clinically as well as radiologically, these lesions were mistaken for pituitary adenomas except for one case where tuberculoma was suspected on imaging. In three patients, there was past history of pulmonary tuberculosis, in one patient of tuberculous meningitis, and in one patient, of spondilytis of the spine. In one patient there was cervical lymphadenopathy along with features of acromegaly (also proved by high levels of serum growth hormone) and radiology revealed a pituitary pathology. Microscopic examination of the excised lesion revealed a composite lesion consisting of a pituitary adenoma and tuberculoma, which has not been documented in literature to date. One patient died during the hospital stay. All the other patients were put on antitubercular chemotherapy following surgery and had good outcomes.

CONCLUSION

Intrasellar tuberculomas are rare. These may be suspected in female patients especially if radiological imaging shows involvement of paranasal sinuses and pituitary fossa along with thickening of pituitary stalk. Simultaneous involvement of clivus may also be an additional feature. The incidence of pituitary tuberculosis is likely to increase with a rise in the incidence of AIDS.

Imaging in pituitary tuberculosis

Tuberculosis of the pituitary gland is extremely uncommon and may masquerade as a nonfunctional pituitary neoplasm. We describe imaging findings in three patients with pituitary tuberculosis and review the pattern of involvement and importance of imaging in its management. An accurate diagnosis was found to be important in these cases as antituberculous chemotherapy was curative.

Hypophyseal tuberculoma: direct radiosurgery is contraindicated for a lesion with a thickened pituitary stalk: case report

OBJECTIVE AND IMPORTANCE

Hypophyseal tuberculomas are extremely rare lesions. The recognition of hypophyseal tuberculomas in the differential diagnosis of pituitary tumors is important, even with no evidence of systemic tuberculosis.

CLINICAL PRESENTATION

A 27-year-old female patient presented with continuous, dull, generalized headaches and amenorrhea, with no history of visual diminution, galactorrhea, or endocrinological abnormalities and no evidence of systemic tuberculosis. The patient exhibited a normal water balance, without polyuria or polydipsia. A gynecological examination, including an endometrial biopsy for amenorrhea, did not reveal any abnormalities. Perimetric and endocrinological examination results were normal. Contrast magnetic resonance imaging revealed a dense enhancing intrasellar mass, with thickening of the pituitary stalk.

INTERVENTION

Sublabial rhinoseptal transsphenoidal decompression of the lesion was performed. The histopathological features were consistent with a diagnosis of tuberculoma, and acid-fast bacilli were demonstrated in the surgically removed tissue with Ziehl-Neelsen staining. As soon as the histopathological features were known, the patient underwent a lumbar puncture for cerebrospinal fluid analysis, which indicated normal findings. An intradermal tuberculin test yielded negative results. The patient was treated with medical therapy for 18 months, and complete resolution of the lesion was observed in follow-up examinations.

CONCLUSION

Hypophyseal tuberculomas are often mistaken for pituitary adenomas. The finding of a thickened pituitary stalk in contrast magnetic resonance imaging scans may be useful for the differentiation of these lesions from pituitary adenomas. Direct radiosurgery is not an appropriate primary treatment method for pituitary adenomas and is principally restricted to elderly, medically unfit patients with microadenomas and patients with residual or recurrent tumors after microsurgery. It is contraindicated for patients who exhibit a thickened pituitary stalk in contrast magnetic resonance imaging scans.

Imaging of sellar and parasellar pathology

This article reviews the complex anatomic relationships between structures in the sellar and parasellar regions. Normal anatomy and the normal imaging spectrum are reviewed, with emphasis on the diversity of pathology that originates from this region. Both CT and MR imaging may be used to evaluate the sellar and parasellar regions. This article discusses how modern imaging techniques enable characterization of the many lesions that alter the structure and function of normal sellar and parasellar anatomy.

Hyperprolactinemia associated to calcification of the pituitary stalk. Case report

In this work, the authors report the case of a female patient with 24 years of age with hyperprolactinemia, who presented a pituitary stalk calcification as seen by CT scan. Once other possible etiologies were excluded, we concluded that the calcification was probably related to hyperprolactinemia caused by interruption of the input of dopamine to the pituitary gland.

Tuberculoma of the cavernous sinus: case report

OBJECTIVE AND IMPORTANCE

The cavernous sinus is an exceptional location for intracranial tuberculomas. A rapid diagnosis, based on pathological findings, improves the prognosis.

CLINICAL PRESENTATION

A case of left cavernous sinus tuberculoma, revealed by frontal headaches and ipsilateral palsies of Cranial Nerves III and V, in a 48-year-old patient is reported. The lesion mimicked an aggressive meningioma in radiological examinations.

INTERVENTION

The lesion was excised through a subtemporal approach. The diagnosis was based on the pathological examination of the mass. Postoperative antituberculous chemotherapy completed the treatment. Neurological symptoms regressed rapidly.

CONCLUSION

Although the incidence of intracranial tuberculomas is decreasing in developed countries, a high index of suspicion must be maintained for the diagnosis of intracranial masses in the presence of risk factors for tuberculosis.

Pituitary abscess: a series of six cases

Pituitary abscess is a rare condition occurring in various age groups. Only about a hundred cases have been reported in the literature. We describe six cases that constitute 0.6% of all the pituitary lesions operated at this centre in the last 10 years. All the patients presented with visual symptoms, though systemic features of infection were present in only two cases. The abscess was seen in association with adenoma in two cases and Rathke's cleft cyst in one. One patient developed an abscess following surgery for pituitary adenoma. The offending organisms was fungal in two cases, mycobacterium in one, bacterial in one and two cultures were sterile. Preoperative diagnosis is difficult and a high degree of suspicion in ring enhancing lesions of the sella is required.

Sellar tuberculoma: report of two cases

Hypophyseal tuberculomas are exceptionally rare. We report two patients with sellar tuberculoma but with no evidence of concurrent extrasellar disease. Although the lesion is often mistaken for adenoma, there are characteristic radiological features: intense enhancement on contrast CT and thickening of the pituitary stalk on MRI in 86% of cases. Accurate diagnosis is important because pituitary tuberculoma is curable.