Angioinvasive aspergillosis in the pituitary fossa

Case contributed by RMH Neuropathology

Presentation

Patient with T2DM presents with aphasia and complete left third nerve palsy, up-gaze palsy. Previous history of pituitary macroadenoma and ileocaecal neuroendocrine tumour resected.

Patient Data

Age: 65
Gender: Female
CT

CT Brain (two years earlier)

Enlarged pituitary fossa, remainder of the exame is unremarkable (CT brain scan performed two years previously to the presentation). 

MRI

MRI Brain (two years earlier)

To be added. 

MRI

MRI Brain (ischaemia protocol - related with the current presentation)

No evidence of midbrain infarction or mass in the interpeduncular cistern. Only non contrast T1 sequences targeted to the pituitary have been performed, but on these images, it appears that the suprasellar component of the tumour is now contacting the inferior surface of the chiasm, not present on the corresponding location on MRI.

In addition, there appears to be a focus of diffusion restriction (note this is close to bone) at the site of this solid component of the pituitary tumour on the left of the sella that is protruding superiorly into the suprasellar cistern. No T1 hyperintensity or increased right sided stalk deviation. The left cavernous sinus appears invaded, but not significantly changed.

Definite diffusion restriction in the left caudate head, in keeping with acute infarction. There are also patchy diffusion restriction in the left occipital lobe. Equivocal diffusion restriction along the left hippocampus.

Bilateral deep white matter FLAIR hyper intensities are slightly more prominent. Bilateral FLAIR hyper intensities in the pons are again noted.

Conclusion: On limited T1 non contrast sequences, there appears to be increased left suprasellar tumour mass effect on the chiasm since the previous MRI. No definite evidence of hemorrhage, but hyperacute hemorrhage may be T1 isointense. After hours radiology reg will contact the stroke team to determine best timing of recalling the patient for further detailed evaluation of this region with FIESTA, thin slice T2 coronals, and contrast.

Left caudate head infarct.

MRI Brain

Comparison made with the imaging from earlier today.

A T2 weighted coronal sequence through the pituitary fossa was obtained. Despite the appearance on the T1 pre contrast scan earlier today, the optic chiasm on this T2 sequence is not contacted by the sellar/suprasellar mass, and appears unchanged from the T2 sequence performed previously.

FIESTA sequence demonstrates a large volume of movement artifact and is non-diagnostic. The patient could not be sedated after-hours when this study was performed. Post-contrast study also not performed. This was discussed with the neurosurgical unit who will organise appropriate in-hours sedation.

Thin axial T2 images through the brainstem demonstrate no focal abnormality, other than minor chronic small vessel ischaemic change throughout the cord is mild tracts and pons. No dorsal midbrain/tectal lesion, no compression of the superior colliculi.

Heterogeneous enhancement of the pituitary region with enlargement of the pituitary fossa and displacement of the infundibulum towards the right is again noted. There appears to be invasion of both cavernous sinuses, particularly on the left with enhancing tissue encircling the internal carotid artery. Additionally, on the postcontrast T1 coronal sequence from today, thin enhancement is seen coating the optic chiasm and left optic nerve. Significance of this is uncertain, however it was not present previously. No convincing leptomeningeal enhancement can be detected elsewhere.

Within the very posterior aspect of gyrus rectus on the left, extending superiorly to the floor of the frontal horn of the left lateral ventricle (at most involving the most inferior part of the head of caudate) is a subcortical region of high T2 signal which does not suppress on flair and does not demonstrate contrast enhancement. This region is shown to abnormally restrict on the earlier study consistent with infarction.

Left occipital cortical and left hippocampal increased T2 signal is demonstrated, (series 3 image 19) which correlates with restricted diffusion in the earlier study from June 18, and represents further acute ischaemic change.

Conclusion:

Multiple areas of increased T2 signal are again noted in the territories of previously demonstrated restricted diffusion. Leptomeningeal enhancement surrounding the left side of the optic chiasm is a new finding when compared to previous studies, although the significance is uncertain. A leptomeningeal process (infection/malignancy) is suspected and further assessment with lumbar puncture is recommended. Cranial nerve palsies on the left yearly relate to cavernous sinus invasion by pituitary tumour.

Pathology

Post-mortem

Report pending. 

PlayAdd to Share

Case information

rID: 39676
Case created: 15th Sep 2015
Last edited: 19th Sep 2015
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.