Primary Pituitary Abscess: Two Case Reports.

Introduction Pituitary abscess is a rare disorder that represents a small fraction of all pituitary lesions. In this report, we present two additional cases with unique features to promote awareness and prompt surgical intervention. Case Presentations A 42-year-old male presented with headache, photophobia, subjective fever, dizziness, imbalance, nausea, and vomiting. A pituitary hormone panel confirmed hypothyroidism and suggested central hypogonadism and secondary adrenal insufficiency. Magnetic resonance imaging (MRI) showed a large sellar mass measuring 2.5 cm × 1.8 cm × 1.6 cm (CC × XT × AP). A 76-year-old woman presented with several months of headaches and unsteady gait in the setting of a known previously asymptomatic sellar lesion, measuring 1.8 cm × 1.2 cm × 1.5 cm (XT × CC × AP). Repeat MRI demonstrated possible hemorrhage within the lesion. In both cases, a preliminary diagnosis of pituitary macroadenoma was made, but transsphenoidal surgery revealed an encapsulated abscess; cultures obtained from the abscesses stained for gram-positive bacteria. Conclusion Pituitary abscess is a rare, potentially life-threatening disorder that may be easily mistaken for other sellar lesions. In this review, we contribute two additional cases of pituitary abscesses to increase awareness and emphasize the importance of proper diagnosis and management.

Infarctive Apoplexy of Previously Healthy Pituitary Glands: A Small Case Series and Literature Review.

Introduction We present two cases of suspected pituitary apoplexy found instead to be infarcted pituitary glands without histopathologic evidence of neoplastic cells, likely resulting from spontaneous infarction of previously healthy pituitary glands. Case Presentations The first case is a 55-year-old man who presented with a pulsating headache, nausea, and several months of decreased libido, polyuria, and polydipsia. Magnetic resonance imaging (MRI) revealed a rim-enhancing sellar/suprasellar mass with evidence of recent hemorrhage on the right. Testosterone, follicle-stimulating hormone, and luteinizing hormone levels were suppressed. Analysis of the resected specimen showed fibrocollagenous tissue with evidence of old hemorrhage and microscopic focus of necrotic tissue. The second case is a 56-year-old man who presented with a throbbing headache, associated nausea, and 6 weeks of polyuria and polydipsia. Testosterone levels were found to be low, and 8-hour water deprivation test showed evidence for partial diabetes insipidus. MRI revealed a mass on the right side of the pituitary gland, with evidence of likely hemorrhage on the left. Analysis of the resected specimen showed necrotic tissue without neoplastic cells. Conclusion When evaluating small pituitary lesions in patients presenting with indolent onset of pituitary insufficiency, there should be a high degree of suspicion for an infarcted pituitary gland.

High-Grade Ectopic Pituitary Adenoma within the Cerebellopontine Angle: A Case Report.

Ectopic pituitary tumors are neoplasms with no connection to the pituitary gland and are commonly deposited in other areas of the anterior skull base. A 32-year-old woman presented with a 3-month history of right-sided facial weakness, sensorineural hearing loss, diplopia, and severe headaches. Physical examination revealed a mid-dilated sluggishly reactive right pupil with slight limitation in all gazes, as well as right-sided orbicularis weakness, lagophthalmos, and decreased facial sensation. A magnetic resonance imaging (MRI) of the head without contrast revealed a 3.7 × 1.8 × 2.6 cm mildly enhancing mass in the right internal acoustic meatus and along the petrous ridge. The case was brought before the institution's tumor board, where concern for higher grade pathology, such as hemangiopericytoma, was discussed. Per patient preference, surgical biopsy of the tumor was performed. Immunohistochemical staining revealed a World Health Organization (WHO) grade II neuroendocrine tumor, with cells staining positive for synaptophysin, chromogranin, and CD56, with a K i -67 index of 8%. In addition to the ectopic location, this pituitary tumor was noted to be aggressive in nature based on its high K i -67 index. Surgical excision and radiologic therapy of tumors involving the CPA are appropriate treatments in most cases.

A case of pituitary apoplexy mimicking viral meningitis.

Pituitary apoplexy (PA) is a clinical syndrome caused by ischemia or hemorrhage of the pituitary gland, typically in the context of an adenoma. It typically presents with a thunderclap headache and sterile cerebral spinal fluid (CSF). The authors identify a case of PA, which initially presented with the signs and symptoms of viral meningitis. Presentation of Case: A 44-year-old man presented to the emergency department with headache, nuchal rigidity, fever, and delirium. The patient reported a 10-year history of chronic that were partially responsive to acetaminophen. Four days after admission, the patient developed right-sided cranial nerve III, IV, and VI palsies. Labs revealed anemia and hyponatremia. The CSF was leukocytic, lymphocyte-predominant, and had elevated protein. In addition to these results, negative CSF bacterial cultures led the care team to believe this case was viral meningoencephalitis. Routine MRI of the brain at presentation revealed a 3.1×2.5×3.2 (craniocaudal×anterior posterior×transverse) expansile mass centered within the sella turcica. An endocrine workup revealed hypopituitarism. The diagnosis of PA was then made. A microscopic transsphenoidal resection of the sellar mass was performed, and histopathologic analysis confirmed necrotic pituitary adenoma tissue. Following an uncomplicated procedure, the patient recovered fully from his cranial nerve palsies and continues to do well. Discussion: Because life-threatening hypotension from acute adrenal insufficiency can be caused by PA, timely diagnosis is crucial. When a patient presents with meningism, PA should be included in the differential diagnosis. Conclusion: This report illustrates a case of PA presenting with symptoms and a CSF profile classically associated with viral meningitis.

Medical malpractice and intracranial hemorrhages in the U.S.: An analysis of 121 cases over 35 years.

Introduction: Though all physicians are at risk for medical malpractice litigation, those in surgical specialties, particularly neurosurgeons, are at increased risk. Because intracranial hemorrhages are a life-threatening and commonly misdiagnosed condition, the aim of this study is to identify and increase awareness of factors associated with litigation in cases of intracranial hemorrhages. Methods: The online legal database Westlaw was utilized to query public litigation cases related to the management of intracranial hemorrhages between 1985 and 2020. Various search terms were used to identify cases, and the following variables were extracted: plaintiff demographics, defendant specialty, trial year, court type, location, reason for litigation, plaintiff medical complaints, trial outcomes, and payouts for both verdicts and settlements. Comparative analysis was performed between cases decided in favor of the plaintiff and in favor of the defendant. Results: A total of 121 cases met inclusion criteria. The most common type of hemorrhage was subarachnoid (65.3%), and the most common cause of hemorrhage was cerebral aneurysm/vascular malformation (37.2%). Most cases were brought against a hospital or healthcare system (60.3%), followed by emergency medicine physicians (33.1%), family medicine physicians (10.7%), and neurosurgeons (6.6%). Failure to diagnose was the most common reason for litigation (84.3%). Cases most frequently resulted in verdicts favoring the defense (48.8%), followed by settlements (35.5%). Plaintiffs were found to be significantly younger in cases ruled in favor of the plaintiff than in cases ruled in favor of the defense (p = 0.014). Cases ruled in favor of the plaintiff were also significantly more likely to involve a neurologist (p = 0.029). Conclusions: Most cases of intracranial hemorrhage resulting in malpractice litigation were classified as subarachnoid hemorrhages and caused by aneurysm/vascular malformation. Most cases were brought against hospital systems, and failure to diagnose was the most common reason for litigation. Cases resulting in verdicts in favor of the plaintiff were significantly more likely to involve younger plaintiffs and neurologists.

Imaging score for differentiation of meningioma grade.

PURPOSE: We sought to establish a comprehensive imaging score indicating the likelihood of higher WHO grade meningiomas pre-operatively. METHODS: All surgical intracranial meningioma patients at our institution between 2014 and 2018 underwent retrospective chart review. Preoperative MRI sequences were reviewed, and imaging features were included in the score based on statistical and clinical significance. Point values for each significant feature were assigned based on the beta coefficients obtained from multivariate analysis. The imaging score was calculated by adding up the points, for a total score of 0 to 5. The predictive ability of the score to identify higher-grade meningiomas was evaluated. RESULTS: Ninety patients, 50% of whom had a postoperative diagnosis of WHO grade II meningioma, were included. The mean age for the population was 59.9 years and 70% were female. Tumor volume ≥ 36.0 cc was assigned 2 points, presence of irregular tumor borders was assigned 2 points, and presence of peritumoral edema was assigned 1 point. The probability of having a WHO grade II meningioma was 0% with a score of 0, 25.0% with a score of 1, 38.5% with a score of 2, 65.4% with a score of 3, and 83.3% with a score of 4 or greater. A threshold of ≥ 3 points achieved a recall of 0.80, precision of 0.73, F1-score of 0.77, accuracy of 0.76, and AUC of 0.82. CONCLUSION: The proposed imaging scoring system had good predictive capability for WHO grade II meningiomas with good discrimination and calibration. External validation is needed.

Silent Corticotroph and Somatotroph Double Pituitary Adenoma: A Case Report and Review of Literature.

Clinically silent double pituitary adenomas consisting of corticotroph and somatotroph cells are an exceedingly rare clinical finding. In this report, we present the case of a 28-year-old man with a 1-year history of recurrent headaches. Imaging revealed a 2.1 (anterior-posterior) × 2.2 (transverse) × 1.3 (craniocaudal) cm pituitary adenoma invading into the left cavernous sinus and encasing the left internal carotid artery. Endoscopic transnasal resection was performed without complications. Immunohistochemical staining revealed a double adenoma consisting of distinct sparsely granulated somatotroph and densely granulated corticotroph cells that were positive for growth hormone and adrenocorticotropic hormone, respectively. K i -67 index labeling revealed a level of 6% within the corticotroph adenoma. No increase in serum growth hormone or adrenocorticotropic hormone was found, indicating a clinically silent double adenoma. While transsphenoidal surgery remains a first-line approach for silent adenomas presenting with mass effects, increased rates of proliferative markers, such as the K i -67 index, provide useful insight into the clinical course of such tumors. Determining the K i -67 index of silent pituitary adenomas could be valuable in predicting recurrence after initial surgical resection and identifying tumors that are at an increased risk of needing additional therapeutic interventions or more frequent surveillance imaging.

Diagnostic and Prognostic Utility of Optical Coherence Tomography in Patients With Sellar/Suprasellar Lesions with Chiasm Impingement: A Systematic Review/ Meta-Analyses.

BACKGROUND: In this review, we appraised the current literature on the utility of optical coherence tomography (OCT) as a diagnostic and predictive factor for postoperative visual function outcomes in patients with sellar/suprasellar lesions with chiasmal impingement. METHODS: A systematic search of PubMed, CINAHL, Scopus, and Cochrane Library was conducted following PRISMA guidelines. Included studies described diagnostic or prognostic utility of OCT in patients with sellar/suprasellar lesions with chiasmal impingement. Meta-analysis was represented as mean difference (MD) with 95% confidence intervals. Meta-regression was performed to determine predictive factors of visual outcomes. RESULTS: Forty-eight articles were identified for final pooled analysis, representing a total of 2435 patients with compressive sellar/suprasellar lesions and 952 healthy controls. Mean age was 43.3 (11.4) years, with 1494 (48.8%) male and 1566 (51.2%) female patients. Mean retinal nerve fiber layer (RNFL) was significantly different in the study population compared with healthy controls (75.8 µ [13.2] vs. 91.4 µ [10.8], P < 0.00001). The nasal segment of RNFL had the largest mean difference (MD -9.76 [-12.39, -7.13], P < 0.0001). Visual acuity, visual field mean deviation, and visual field pattern standard deviation all showed significant differences between the study population and healthy controls as well (P < 0.0001). Meta-regressions showed significant predictive capability of preoperative RNFL in determining visual function outcome (P < 0.05). CONCLUSIONS: Our findings provide promising support for the growing evidence that OCT parameters can be utilized as both a diagnostic and prognostic tool for patients with compression of the optic apparatus. There is a need for further studies to gain a better understanding of OCTs and to improve patient outcomes.

Medical Malpractice and Vestibular Schwannomas: A Nationwide Review.

OBJECTIVE: Most surgeons face litigation related to the care of their patients, with specialties including neurosurgery facing a particularly high risk. Diagnosis and management of vestibular schwannomas can be challenging, potentially giving rise to medicolegal proceedings. Accordingly, a full appreciation of the medicolegal implications of treating these challenging tumors is warranted. METHODS: A systematic search of the Westlaw Edge legal database was conducted to identify all cases of medicolegal proceedings related to the management of vestibular schwannomas. All cases identified by the search were screened in full, and relevant cases included for analysis. Variables pertaining to the nature of the case and legal outcomes were extracted. RESULTS: A total of 38 cases were included in this analysis from 11 U.S. states. Failure to diagnose and negligent surgery were the most common allegations. Neurosurgeons were the most frequently implicated specialists followed by otolaryngologists and radiologists. A verdict was reached in 30 cases, with the jury finding in favor of the defendant(s) in most cases (n = 26, 87.0%), a proportion that increased across each decade of the study period. Damages were paid out in 11 cases, with a mean value of $1,534,446. Mean value of damages paid in verdicts in favor of the plaintiff were larger than those in settlements ($2,116,543 and $1,385,457, respectively). CONCLUSIONS: The data presented provide a comprehensive overview of medicolegal proceedings related to the management of vestibular schwannomas. This study provides clinicians with a greater appreciation of the medicolegal implications of treating vestibular schwannomas.

Medical malpractice and meningiomas: an analysis of 47 cases.

OBJECTIVE: Among medical practices, surgical fields, including neurosurgery, are at a high risk for medical malpractice litigation. With meningiomas contributing to 10% of the total neurosurgery litigation cases, the aim of this study was to identify demographic characteristics, reasons for litigation, and surgical complications commonly reported in these cases. This analysis serves to increase neurosurgeons' awareness of factors associated with medical malpractice litigation. METHODS: The online legal database Westlaw was utilized to query public litigation cases related to the medical management of meningiomas between December 1985 and May 2020. Variables extracted included the following: plaintiff and defendant demographics, litigation category, plaintiff medical complaints, and trial outcomes. The authors compared these characteristics between cases with decisions in favor of the defendant and those with decisions in favor of the plaintiff. RESULTS: A total of 47 cases met the inclusion criteria. Failure to diagnose (68.1%) was the most common type of malpractice claim, and surgical complications (19.1%), motor weakness (33%), and financial loss (33%) were cited as the most common postoperative complaints. Individual specialties that most often required defense due to malpractice claims were radiology (21.7%) and neurosurgery (19.6%). The jury verdict was in favor of the defense in 51.1% of cases and in favor of the plaintiff in 27.7% of cases. A settlement was reached in 19.1% of cases. The mean payout for a verdict in favor of the plaintiff was $3,409,650.22, while the mean payout for settlements was $867,555.56. The greatest average payout for specialties was in neurosurgery at $3,414,400, followed by radiology at $3,192,960. Cases with a verdict in favor of the plaintiff were more likely to involve an internal medicine physician as a defendant (p = 0.007). CONCLUSIONS: Over one-half of the cases resulted in a defendant's verdict with failure to diagnose cited as the most common reason for litigation. Radiology and neurosurgery were the most common specialties for legal cases and also had some of the largest average payouts based on specialty. Motor weakness and financial loss were the most common plaintiff postoperative complaints. These findings may inform surgeons on active measures to take, such as increasing focus on diagnostic accuracy and reducing specific postoperative complaints, such as motor weakness, through risk management and prophylactic measures, to reduce unfavorable legal outcomes.