HPI: The patient is a 77-year-old female referred for evaluation of a sella mass with associated vision loss/visual field defects. She also complains of 6 months to 1 year of gait instability. She denies visual complaints, but formal visual field testing demonstrated: "bilateral defects suggesting optic chiasm/optic nerve dysfunction."
PMH: Protein S deficiency - chronically taking Coumadin; depression; obstructive sleep apnea
Social History: Retired school teacher. Remote smoking history. She does not drink or use illegal drugs.
Family History: skin cancer and heart disease
Exam: Acromegalic features to include prominent forehead, jaw and large hands. Neurologic exam revealed bitemporal visual field deficits.
Pertinent labs: IGF-1: 455 ng/ml (59-177). Other pituitary function labs within normal limits.
Figure 1. Sagittal post contrast T1-weighted imaging demonstrates an enhancing lesion within the sella extending anteriorly to tuberculum sellae.
Figure 2. Coronal post contrast T1-weighted imaging demonstrates an enhancing lesion within the sella extending anteriorly to the dura of the tuberculum sella.
Figure 3. Coronal post contrast T1-weighted imaging demonstrates an enhancing lesion within the sella extending anteriorly to the dura of the tuberculum sella.
1. How would you manage this patient’s hypercoaguable state in the perioperative period?
2. What approach would you use to resect this tumor?
3. Would you place a lumbar drain prior to your surgical approach to resect the lesion?
4. Surgerical resection was performed and pathology demonstrated meningioma. What is the next step to localize the source of ectopic source of GH?
5. Which of the following describes you?
6. I practice in one of the following locations.
6. Please add any suggestions or comments regarding this case:
- Question of meningioma is really or a discussion.If it is really an ectopic GHT I like to add octreotide as per serum level of IGF-1 or hGH.
- I am Neurosurgeon in a publical hospital in Quito Equateur. I have recently a case of meningioma sellar that was operated succesfully ad the outcome is very good
- Why do you give away the meningioma. With elevated GH, I assume Pit. tumor.
- Normally I would do this cas by transnasal transphenoidal approach using microscope. However, after attending the 2 day course of "The Master Class: Tanssphenoidal Pituitary and Expanded Endonasal Surgery" given by Dr. Edward Laws, March 9-10-Boston, MA, I am anxiously waiting for my next case to be done by Transnasal Transphenoidal Endoscopic approach with our ENT colleague. Dr. Kumar Bahuleyan Brain & Spine Center
- it is a very nice case for discusion