Giant cabergoline-resistant prolactinoma in a man who presented with a psychotic episode during treatment: a case report.

BACKGROUND: Prolactinomas are tumors of the pituitary gland that usually respond very well to treatment with cabergoline. Resistance to cabergoline is very rare, but when it occurs, it is a difficult problem to resolve if the tumor is inoperable. CASE PRESENTATION: A 62-year-old white man was treated for a giant macroprolactinoma detected during investigation of a subacute subdural hematoma of the left frontal lobe. The patient was treated with cabergoline for 17 years with a dose ranging from 1.0 mg to 3.5 mg per week. We were not able to normalize his prolactin level, which initially was 14,992 ng/ml and ultimately 1754 ng/ml. The tumor significantly shrank during the follow-up period but persisted. The patient had cardiac valvulopathies that did not worsen. He had an ischemic stroke and developed a psychotic condition that was successfully treated by lowering the cabergoline and administering quetiapine and mirtazapine together. This regimen led to a small increase in the patient's prolactin that returned to previous levels and remained as such until the last medical evaluation. The tumor continued to shrink and had a cystic degeneration in the last evaluation. CONCLUSIONS: Combined use of cabergoline with quetiapine and mirtazapine to treat a psychotic crisis may have contributed to shrinking the tumor in our patient because these antipsychotics have action mediated by growth factors that interfere with growth of pituitary tumors.

Prolactinomas Resistant to Treatment With Dopamine Agonists: Long-Term Follow-Up of Six Cases.

Introduction: Prolactinomas are preferentially treated with dopamine agonists. However, a few adenomas are resistant to this treatment. Objective: To evaluate the characteristics of patients with resistance to dopamine agonists in the long-term. Method: A retrospective study of six cases was made. Patients who did not achieve normalized prolactin blood concentrations and a reduction of more than 50% of the tumor volume with the minimum dose of 3.5 mg per week of cabergoline for 3 months or the maximum supported dose of bromocriptine for 6 months were considered resistant to dopamine agonists. Patients were followed up at the Clinic of Neurology and Endocrinology or the University Hospital of Brasilia. Results: Six patients were selected. Three patients were initially treated with bromocriptine prior to treatment with cabergoline. Four patients were men, and two were women. At the time of diagnosis, ages ranged from 9 to 62 years. Initial prolactin concentrations ranged from 430 to 14,992 ng/mL and in the last assessment ranged from 29.6 to 2,169 ng/mL. The tumor volume ranged from 0.77 to 24.0 mm3. Tumor regression occurred in all patients, ranging from 20 to 100%, but total disappearance of the adenoma with an empty sella occurred in one patient. The maximum weekly doses of cabergoline ranged from 3.0 to 4.5 mg. Follow-up time ranged from seven to 17 years. Normalization of prolactin concentrations occurred only in one woman after 17 years of treatment. Three patients also underwent surgery, but only one woman was cured of the disease. Conclusion: This study confirms that tumors resistant to dopamine agonists are more aggressive, since we did not have any microadenoma; treatment with high dose of cabergoline may reduce the size of the tumor without its disappearance, and that normalization of prolactin concentration rarely occurs. To our knowledge, this is the longest follow-up of a series of cases with resistance to dopamine agonists.

Unilateral dysgenesis of the internal carotid artery: spectrum of imaging findings.

OBJECTIVE: Dysgenesis of the internal carotid artery (ICA) is a broad term comprising hypoplasia, aplasia and agenesis of the vessel. It is a rare anomaly, often clinically silent, that can be confidently diagnosed by means of noninvasive imaging methods. METHODS: After a review of teaching files, 7 patients with unilateral carotid dysgenesis were found, 2 with agenesis of the ICA, 3 with carotid aplasia, and 2 with hypoplasia of the vessel. Computed tomography (CT) and magnetic resonance angiography (MRA) of the brain were performed in all patients, with a complete magnetic resonance of the brain in 3 of them, a CT angiography of the brain in one, and MRA of the cervical arteries in 3. RESULTS: The fetal pattern of arterial circulation was found in 3 patients with agenesis/aplasia of the ICA and the adult pattern was found in 2 patients, being the brain circulation of normal pattern in the patients with hypoplasia of the ICA. Two patients presented signs of reduced flow to the brain hemisphere ipsilateral to the carotid dysgenesis; one of them with an old homolateral brain infarction. CONCLUSION: Far from being just an anatomic curiosity, the dysgenesis of the ICA may have serious consequences if not recognized prior to endarterectomies, carotid ligation or transsphenoidal surgery. As much as one-third of these patients will have intracranial aneurysms as well. The imaging methods, instead being mutually exclusive, are complementary in the evaluation of carotid dysgenesis.

Anomalias congênitas da veia cava inferior: valor dos métodos multiplanares em seu diagnóstico: ensaio iconográfico / Congenital anomalies of the inferior vena cava: importance of multiplanar imaging methods: an iconographic essay

A formação da veia cava inferior é o resultado de um complexo processo embriológico que se dá entre seis e oito semanas de vida intra-uterina. Numerosas variações no desenvolvimento deste vaso podem ocorrer, decorrentes de embriogênese aberrante, resultando no surgimento de variantes anatômicas. Embora boa parte delas seja assintomática, é imperativo que o radiologista esteja familiarizado a elas, já que o seu não-reconhecimento tem implicações médico-legais sérias, como em pacientes candidatos a manuseio cirúrgico abdominal ou procedimentos hemodinâmicos, porexemplo. Neste trabalho, o diagnóstico por imagem das principais anomalias congênitas da veia cava inferior é abordado sob a forma de um ensaio iconográfico, ressaltando-se a importância dos métodos multiplanares (tomografia computadorizada com aquisições volumétricas e ressonânciamagnética) neste contexto.

The inferior vena cava is the result of a complex embryologic process which takes place between 6 and 8 weeks of intra-uterine life. Several variations can occur during this process, and a defective embryogenesis of this vessel may lead to the development ofanatomic variants. Although many of these variants are asymptomatic,the radiologist should be aware of them and of the potential medico-legal issues involved, especially in cases in which abdominal surgery or hemodynamic procedures are contemplated. In thispaper, the major congenital anomalies involving the inferior vena cava are reviewed under the form of a pictorial essay, highlighting the role of the multiplanar imaging methods (volumetric computed tomography and magnetic resonance imaging) in their diagnosis.

Hipoplasia da veia cava inferior: relato de caso e revisão da literatura / Hypoplasia of the inferior vena cava: a case repost and review of the literature

Erros na embriogênese da veia cava inferior podem levar a vários tipos bem conhecidos de anomalias de desenvolvimento deste vaso. Entretanto, hipoplasia de toda a sua extensão abdominal é bastante rara, e a maioria dos casos previamente descritos como hipoplasia da veia cava inferior refere-se, na verdade, a hipoplasia ou atresia segmentares. Os autores descrevem os achados à tomografia computadorizada e à angio-ressonância magnética de um homem de 49 anos com antecedentes remotos de trombose bilateral das veias femorais comuns e hipoplasia de toda a veia cava inferior abdominal, apresentando-se com extensa rede colateral em abdome e pelve (inclusive com evidências de derivação sistêmico-portal), dilatação compensatória do sistema ázigos/hemi-ázigos e doença varicosa grave de membros inferiores. A ocorrência de trombose venosa profunda em pacientes jovens, especialmente quando proximal, bilateral ou recorrente, deve levantar a possibilidade de anomalias da veia cava inferior, sendo a angio-ressonância e a tomografia computadorizada contrastada especialmente úteis neste contexto.

Defective embryogenesis of the inferior vena cava may lead to several well-known types of developmental anomalies of this vessel. However, hypoplasia of the whole abdominal portion seems to be very rare, and most cases previously described as hypoplasia of inferior vena cava are related to segmental hypoplasia or atresia. The authors describe the computed tomography and magnetic resonance angiography findings of a 49-yearold man with remote antecedents of bilateral thrombosis of the common femoral veins and unsuspected hypoplasia of the entire abdominal inferior vena cava incidentally discovered, presenting with extensive collaterals in the abdomen and pelvis (including evidences of systemic-to-portal shunting), compensatory dilatationof the azygous/hemiazygous system and severe varicose disease in his lower limbs. Deep venous thrombosis in youngpatients, especially when proximal, bilateral or recurrent should raise the possibility of anomalies of the inferior vena cava, and magnetic resonance angiography and contrast-enhanced computed tomography are particularly useful in this setting.

Avulsão da espinha ilíaca ântero-inferior: aspectos dos achados de imagem / Avulsion fractures of the interior iliac spine: spectrum of imaging findings

Lesões avulsivas das apófises pélvicas são relativamente comuns em atletas entre 13 e 18 anos, principalmente, no Brasil, entre jogadores de futebol. O diagnóstico é estabelecido clinicamente e através dos exames de imagem. Fases aguda, reparativa e consolidada são encontradas nessas lesões, todas com características de imagem distintas. Enquanto as fases aguda e consolidada habitualmente não apresentam maiores dificuldades diagnósticas, a fase reparativa freqüentemente exibe aspecto agressivo aos exames de imagem, simulando lesão neoplásica. Neste artigo, os autores apresentam os achados de avulsões da espinha ilíaca ântero-inferior às radiografias convencionais, à tomografia computadorizada e à ressonância magnética, enfatizando as características típicas dos três estágios evolutivos destas lesões.

Cavernous angioma of the cavernous sinus: imaging findings.

Cavernous angiomas (cavernomas) of the cavernous sinus are uncommon, with only scattered reports in literature. Unlike their parenchymatous counterparts, they are intensely enhancing para-sellar masses, iso/hypointense in T1- and hyperintense in T2-weighted images. Differential diagnosis with para-sellar meningiomas and schwannomas can be difficult. We report three cases of this condition, describing findings of diffusion-weighted imaging in this kind of lesion for the first time in literature.

Cavernous angioma of the cavernous sinus: imaging findings

Angiomas cavernosos (cavernomas) do seio cavernoso são lesões incomuns, com poucos relatos na literatura especializada. Ao contrário dos cavernomas parenquimatosos, são massas para-selares intensamente captantes, isointensas a hipointensas em T1 e hiperintensas em T2 nas imagens de ressonância magnética. O diagnóstico diferencial com meningiomas e schwannomas para-selares pode ser difícil. Relatamos os achados de imagem de três casos desta entidade, descrevendo os achados da ressonância magnética ponderada em difusão neste tipo de lesão pela primeira vez na literatura.

Síndrome de aicardi e papiloma do plexo coróide: uma associaçäo rara: relato de caso / Aicardi syndrome and choroid plexus papilloma: a rare association: case report

Relata-se o caso clínico de uma criança de 5 meses de idade, do sexo feminino, com achados característicos da síndrome de Aicardi: agenesia do corpo caloso, espasmos infantis, anormalidades oculares ("chorioretinal lacunae" e microftalmia), atraso do desenvolvimento neuropsicomotor e malformaçoes vertebrais com cifoescoliose. Os exames complementares confirmaram o diagnóstico e as imagens neurorradiológicas evidenciaram, além da agenesia do corpo caloso, massa localizada em regiao atrioventricular esquerda (papiloma do plexo coróide). A síndrome de Aicardi associada a papiloma do plexo coróide é rara, sendo este o sétimo caso relatado na literatura. Os autores sugerem que o papiloma do plexo coróide seja considerado tumor característico da síndrome de Aicardi, pois a sua frequência é mais do que coincidental.

Granulomas e tumores cerebrais: dificuldades no diagnóstico diferencial / Granuloma and brain neoplasms: difficulties in the differential diagnosis

Apresentamos 4 pacientes com diagnóstico inicial, através da tomografia computadorizada, de tumor primário e/ou metastático cerebral e que a cirurgia constatou tratar-se de doença granulomatosa (criptococose em 2 casos, blastomicose em 1 e tuberculose em 1. Três pacientes evoluiram para o óbito no pós-operatório imediato e, somente um, portador de tuberculoma, teve boa evoluçäo, após tratamento específico. Estes casos demonstram que a tomografia computadorizada tem excelente sensibilidade, mas limitada especificidade