Traumatic intracranial haemorrhage with incidental carotid dolichoectasia mimicking sellar mass
Presentation
Sustained a fall, had a tonic clonic-seizure in the ER. Intracranial bleeding, fracture?
Patient Data
Large left frontal, parietal and temporal subdural haematoma.
A smaller subdural collection along the left tentorium is more subtle.
Left temporal pole contusion, with small subarachnoid bleeding also layering in the occipital horn of the lateral ventricles.
Prior righttemporal and left frontal extensive ischaemic changes.
Incidental sellar expansile mass-like lesion showing suprasellar propagation (however the widening of the carotid canal contradicts this, and points towards vascular aetiology). Stable compared to an earlier noncontrast CT (not shown). Further workup recommended.
Advanced (Fazekas III) chronic small vessel ischaemic changes.
CTA a few days later after surgical drainage:
Staus post almost complete drainage of the left subdural haematoma. The collection along the tentorium is virtually unchanged.
Subarachnoid blood present in the ventricles and sulci at multiple locations bilaterally.
Bilateral carotid dolichoectasia, with circumferential fusiform aneurysms showing mural thrombi in the C4 segments, more pronounced on the left.
Significant atherosclerosis, about 50% narrowing of the intracranial right vertebral artery.
Incidental heterogeneous, partially cystic thyroid nodules.
Case Discussion
The case demonstrates multiple subdural, subarachnoid and parenchymal contusion haemorrhages with an incidental expansile sellar mass-like lesion, macroadenoma was suggested as a working diagnosis. However, subsequent CTA confirmed it as a result of bilateral extensive carotid dolichoectasia and aneurysms.
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Key take home message: we should train ourselves to increase, or at least maintain our alertness when we encounter significant pathology.
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