Complete endoscopic resection of a pituitary stalk epidermoid cyst using a combined infrasellar interpituitary and suprasellar endonasal approach: case report

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Intracranial epidermoid cysts are benign lesions of epithelial origin that most frequently present with symptoms of mass effect. Although they are often associated with a high rate of residual tumor and recurrence, maximal safe resection usually leads to good outcomes. The authors report a complete resection of an uncommon pituitary stalk epidermoid cyst with intrasellar extension using a combined suprasellar and infrasellar interpituitary, endoscopic endonasal transsphenoidal approach. The patient, a 54-year-old woman, presented with headache, visual disturbance, and diabetes insipidus. Postoperatively, she reported improvement in her visual symptoms and well-controlled diabetes insipidus using 0.1 mg of desmopressin at bedtime and normal anterior pituitary gland function. One year later, she continues to receive the same dosage of desmopressin and is also taking 50 mcg of levothyroxine daily after developing primary hypothyroidism unrelated to the surgical procedure. A combined infrasellar interpituitary and suprasellar approach to this rare location for an epidermoid cyst can lead to a safe and complete resection with good clinical outcomes.

ABBREVIATIONS DI = diabetes insipidus; EEA = endoscopic endonasal approach; GTR = gross-total resection.

Article Information

Correspondence Juan C. Fernandez-Miranda, Department of Neurological Surgery, University of Pittsburgh School of Medicine, 200 Lothrop St., PUH Ste. B-400, Pittsburgh, PA 15213-2582. email: fernandezmirandajc@upmc.edu.

INCLUDE WHEN CITING Published online April 14, 2017; DOI: 10.3171/2016.11.JNS161605.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Goldmann visual field chart of the left eye (left) and right eye (right) revealing bilateral inferior temporal field loss closer to fixation in the left eye and bitemporal relative scotomas. Figure is available in color online only.

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    Coronal T1- (A) and T2-weighted (B) and axial T2-weighted FLAIR (C) MR images showing a mixed-signal lobulated suprasellar mass extending inferiorly into the sella, measuring 1 × 0.7 × 1.8 cm. Sagittal Gd-enhanced T1-weighted MR image (D) shows rim enhancement of the lesion without central enhancement. Ax = axial; Cor = coronal; Sag = sagittal; + C = with contrast.

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    Endoscopic views of the epidermoid tumor. Following an EEA, views are shown of the pituitary gland (PG), optic chiasm (Ch), clival recess (CR), and pituitary stalk (S). The epidermoid tumor initially appears to be posterior to the pituitary stalk and superior to the pituitary gland (A, arrow), but after resection of the superior portion, the resection cavity shows intact stalk surrounding the tumor (B, arrows). The tumor showed yellowish keratinous appearance consistent with an epidermoid (C, circle). Using a 45º endoscope from below allows the gland to be displaced superiorly to access the portion of the epidermoid tumor not visible from a superior position (D, dotted circle). Figure is available in color online only.

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    Comparison between pre- and postoperative images 11 days after surgery. Preoperative sagittal Gd-enhanced T1-weighted MRI (A), postoperative sagittal Gd-enhanced T1-weighted MRI (B), preoperative coronal Gd-enhanced T1-weighted MRI (C), postoperative coronal Gd-enhanced T1-weighted MRI (D), preoperative coronal T2-weighted MRI (E), postoperative coronal T2-weighted MRI (F), preoperative axial FLAIR (G), and postoperative diffusion-weighted MRI (H) show no residual disease and extensive enhancement due to postoperative changes.

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