Pituitary enlargement in patients with cerebrospinal fluid drainage due to ventricular shunt insertion: know the condition and do not mistake for adenoma.

OBJECTIVE: Childhood hydrocephalus patients treated by ventriculo-peritoneal (v.-p.) shunting are sometimes referred years after this therapy for evaluation of suspicious pituitary enlargement. Since pituitary size has been shown to depend on cerebrospinal fluid (CSF) pressure, we assume this phenomenon to be caused by shunt overdrainage. Therefore, we studied pituitary size and morphology in shunted hydrocephalus patients with radiological signs of high CSF drainage. PATIENTS AND METHODS: Retrospective study of pituitary size and morphology in 15 shunted patients with non-tumoral hydrocephalus and 7 shunted hydrocephalus patients due to childhood brain tumor compared to a population mean. In five brain tumor patients also pre- and postsurgical comparisons were performed. RESULTS: Pituitary mid-sagittal size and pituitary volume were significantly higher in both hydrocephalus groups, compared to the population mean (midsagittal size t = 5.91; p < 0.001; pituitary volume, t = 3.03; p = 0.006). In patients available for pre- and postoperative comparison, there was also a significant increase in pituitary size and volume postoperatively (mean preoperative midsagittal height 2.54 ± 1.0 mm vs. 6.6 ± 0.7 mm post-surgery; mean pre-operative pituitary volume 120.5 ± 69.2 mm3 vs. 368.9 ± 57.9 mm3 post-surgery). CONCLUSION: Our results confirmed a significant increase in pituitary size and volume, mimicking pituitary pathology, after v.-p. shunt insertion. This phenomenon can be explained by the Monro-Kellie doctrine, stating that intracranial depletion of CSF-as caused by v.p. shunting-leads to compensatory intracranial hyperemia, especially in the venous system, with the consequence of engorged venous sinuses, most likely responsible for enlargement of the pituitary gland.

Pituitary hyperplasia in childhood primary hypothyroidism: a review.

INTRODUCTION: Pituitary hyperplasia following primary hypothyroidism in pediatric age group population is considered rare with reports of unnecessary neurosurgical intervention for this medically treatable condition. Given the paucity of information on this topic, it is timely to provide clinicians with a comprehensive summary of available research. METHODS: A search of published studies in Pubmed, PsychInfo and Cochrane Database with the terms "pituitary hyperplasia" or "pituitary hypertrophy" and "hypothyroidism" was performed and the results filtered for English language, pediatric (0-18 years) population and CT or MRI confirmed findings. 55 studies met the inclusion criteria. Data for a total of 110 patients with pituitary hyperplasia following primary hypothyroidism were extracted. The study population included 29 males and 81 females (M: F= 0.35:1). Patient age varied from 3 weeks to 18 years with a mean age of 10.22 years. RESULTS: The most common clinical presentations included growth retardation, constipation and features of myxedema which were present in 78, 36 and 18 percent of children included in our review. Neuroimaging showed the mean (SD) pituitary height being 13.48 mm (4.72 mm). All of the patients achieved resolution of their pituitary mass and clinical as well as biochemical abnormalities 1 to 26 months after initiation of thyroid hormone replacement therapy, with an average time interval of 7.22 months. Our review has tried to delve in the pathophysiology as well as clinical, biochemical and radiological aspects of pediatric pituitary hyperplasia secondary to primary hypothyroidism and provide recommendations for treatment and follow-up. This may help anyone concerned gain a substantial knowledge on this topic.

Reversible growth failure and complete GH deficiency in a 4-year-old girl with very early Hashimoto's thyroiditis and subsequent hyperplasia of pituitary thyrotroph cells.

UNLABELLED: Hashimoto's thyroiditis is a well-known cause of growth retardation in adolescence. It is less frequently seen in children and rarely seen in infants. A 4-year-old girl was referred to our clinic for a second opinion before starting growth hormone (GH) treatment. Linear growth had markedly declined in the past 2 years, with height -3.4 standard deviations. GH deficiency was complete. She had dry, gray-sallow skin and bloated abdomen, but no goiter. The parents reported fatigue and constipation. Hormonal evaluation revealed TSH 629.5 mIU/ml, free T4 0.08 ng/dl, and prolactin 17.2 ng/ml. Bone age was 2 years. Antibodies to thyroglobulin and thyroid peroxidase were positive, suggesting Hashimoto's thyroiditis. Brain magnetic resonance imaging showed anterior pituitary hyperplasia. After 3 years of L-thyroxine therapy, she was symptomless, her height was -0.6 standard deviations, and the TSH level was normal. Brain magnetic resonance imaging showed regression of the pituitary hyperplasia. CONCLUSIONS: This report describes a patient with Hashimoto's thyroiditis and pituitary hyperplasia, both quite rare in very young children. Acquired hypothyroidism may appear after neonatal screening and therefore should not be overlooked in investigations of short stature, even when clinical signs of hypothyroidism are absent. WHAT IS KNOWN: • Hashimoto's thyroiditis and pituitary hyperplasia are rare in very young children. • Acquired hypothyroidism can appear after negative neonatal screening and should not be overlooked. What is New: • Short children should be evaluated for growth hormone deficiency but only after excluding other causes, particularly hypothyroidism, as we report a child with this disease but no clinical signs of it.

Characteristics of girls with pituitary hyperplasia and sexual precocity secondary to primary hypothyroidism.

AIM: To investigate the different characteristics of girls with pituitary hyperplasia secondary to primary hypothyroidism (PPH), with and without sexual precocity. METHODS: Pituitary hyperplasia secondary to primary hypothyroidism girls were divided into two groups: group A, with sexual precocity (n = 8), and group B, without sexual precocity (n = 14). The following values were measured before and after 3 months levothyroxine therapy: free triiodothyronine (FT3 ), free thyroxine (FT4 ), thyrotropin (TSH), follicle-stimulating hormone (FSH), luteinising hormone (LH), prolactin (PRL), estradiol (E2 ), testosterone (T), pituitary height, uterine volume (UV), ovarian volume (OV) and follicular diameter (FD). RESULTS: Thyrotropin, FSH, PRL, E2 , T, pituitary height, UV, OV and FD were higher in group A than group B (all p < 0.05); FT3 , FT4 and LH levels were not different (all p > 0.05). In all of the PPH girls, pituitary height was correlated with FT3 , FT4 and PRL (r = -0.545, p = 0.009, r = -0.567, p = 0.006 and r = 0.666, p = 0.001, respectively). PRL was positively correlated with UV, FD and FSH (r = 0.581, p = 0.005, r = 0.482, p = 0.031 and r = 0.667, p = 0.001, respectively), and FSH was positively correlated with OV (r = 0.522, p = 0.013). These abnormalities regressed after therapy. CONCLUSION: Pituitary hyperplasia secondary to primary hypothyroidism girls with sexual precocity have increased plasma TSH, FSH, PRL, E2 and T levels, pituitary height and uterine, ovarian and follicular size.

Pituitary enlargement in a carotid-cavernous fistula: An atypical imaging manifestation.

A carotid-cavernous fistula is a rare abnormal communication between carotid vasculature and the cavernous sinus. Development of a carotid-cavernous fistula often results from trauma, but may be spontaneous in the setting of predisposing risk factors. Suspicion for a spontaneous fistula is understandably low on routine non-contrast imaging. In this article, we present a case of a carotid-cavernous fistula initially presenting with the potentially underrecognized imaging manifestation of diffuse pituitary enlargement identified on a non-contrast CT, later revealed to be due to the presence of the fistula.

Radiological evolution of pituitary hyperplasia in primary hypothyroidism and its differentiation from nonfunctioning pituitary adenoma coexisting with primary hypothyroidism.

PURPOSE: In a patient with elevated thyroid stimulating hormone (TSH, >50 µIU/ml) with sellar mass, it is crucial to differentiate isolated pituitary hyperplasia (IPH) from primary hypothyroidism coexisting with nonfunctioning pituitary adenoma (PHCNFPA) pre-operatively to avoid unwarranted surgery in the former condition. Here, we describe patients having pituitary mass/enlargement with markedly elevated TSH (>50 µIU/ml) and attempt to find the differentiating features between IPH and PHCNFPA. METHODS: This is a retrospective study conducted at a tertiary care center. Case records of patients presenting between January 2020 and December 2022 with elevated TSH (>50 µIU/ml) for whom magnetic resonance imaging (MRI) of the sella was available were reviewed. Demographic details, symptomatology, clinical examination findings, thyroid function tests, data on pituitary hormonal excess and deficiencies, MRI findings, and details regarding levothyroxine supplementation were noted. Based on the final diagnosis, the patients were categorized into two groups: PHCNFPA and IPH. RESULTS: Five and 11 patients were diagnosed with PHCNFPA and IPH, respectively. The median (IQR) age at presentation of patients with PHCNFPA was significantly higher than that of IPH patients [37 (28-60.5) vs. 21 (10-21.5) years, p: 0.002]. A longer duration of hypothyroid symptoms was noted in the IPH group whereas visual field defects and corticotropin deficiency were more frequent and the pituitary lesion size was greater in PHCNFPA. Thyroid function tests were not different between the two groups. The pituitary enlargement in IPH was initially an increase in pituitary height that progressed to symmetrical nipple-, dome- or tent-shaped enlargement. Besides this characteristic enlargement pattern, isointense appearance on T1-weighted and T2-weighted images, homogeneous contrast enhancement, and prompt regression of pituitary lesion with levothyroxine replacement were characteristic of IPH whereas heterogeneous enhancement, cystic/hemorrhagic change, and ≥Knosp III invasion were characteristic of PHCNFPA. Peripheral rim enhancement and Knosp I-II parasellar extension were not uncommon in patients with IPH and did not distinguish it from PHCNFPA. CONCLUSIONS: The present study reports the radiological evolution of IPH and a unique series of PHCNFPA along with the distinguishing characteristics between them.

Pituitary Hyperplasia Due to Longstanding Primary Hypothyroidism: A Case Report and Comprehensive Review of the Literature.

Hypothyroidism is a frequently diagnosed endocrine disorder. Common signs and symptoms include fatigue, cold intolerance, hoarseness, dry skin, constipation, a slow relaxation phase of deep tendon reflexes, and bradycardia. However, some patients may exhibit atypical signs and symptoms, which can result in diagnostic confusion. Pituitary hyperplasia resulting from longstanding primary hypothyroidism was first described by Niepce in 1851. It is usually asymptomatic, but sometimes, in addition to symptoms of overt hypothyroidism, patients may complain of headaches, hypopituitarism, visual field impairment, and hyperprolactinemia. Furthermore, on imaging, pituitary hyperplasia can be mistaken for a pituitary adenoma. Distinguishing between the two is crucial, as their management differs; the former often responds to thyroid hormone replacement therapy, while the latter might need treatment with surgery and/or radiotherapy. Here we describe a patient who developed pituitary hyperplasia in the setting of longstanding uncompensated primary hypothyroidism due to a lack of compliance with levothyroxine replacement therapy. We also review the clinical, laboratory, and radiologic findings of the case reports available in the literature up to now in order to improve the knowledge and the care of the disease.

A Case of Exaggerated Pituitary Hyperplasia in a Pregnant Woman.

Pituitary hyperplasia occurs as a result of an increase in pituitary cell subtypes. It can be a consequence of either a physiological or pathological condition. In our case, a 31-year-old pregnant woman at 16 weeks gestation presented with headaches and vision changes. Visual field testing demonstrated bitemporal hemianopsia, and magnetic resonance imaging (MRI) brain showed enlargement of the pituitary with compression of the optic chiasm. She was treated with cabergoline and steroids, and her symptoms improved. In a subsequent pregnancy, the patient developed similar symptoms, and with cabergoline treatment, her symptoms resolved. A postpartum MRI of her brain revealed a decrease in pituitary size back to baseline with normal pituitary hormone levels. This patient's likely diagnosis was physiologic pituitary hyperplasia. Pituitary hyperplasia can be difficult to diagnose since there are no explicit guidelines. Through deduction of imaging findings and hormonal levels, diagnosis of pituitary hyperplasia becomes a more manageable task.

Primary hypothyroidism presenting as neuropsychiatric symptoms and pituitary enlargement in a young woman: illustrative case.

BACKGROUND: Pituitary adenomas are the most common cause of pituitary enlargement and can potentially warrant surgical intervention. However, there are physiological causes of pituitary enlargement that can be reversed with hormone replacement alone. OBSERVATIONS: A 29-year-old female presented with acute onset paranoia to the psychiatry department. A computed tomography scan of the head revealed a 2.3 cm sellar mass with confirmation on magnetic resonance imaging. Testing showed a markedly elevated thyroid-stimulating hormone 1,600 µIU/mL (0.470-4.200 µIU/mL), suggesting pituitary hyperplasia. Treatment with levothyroxine replacement resulted in marked improvement in symptoms and resolution of pituitary hyperplasia on four month follow up. LESSONS: This rare presentation of severe primary hypothyroidism highlights the importance of evaluating for physiological causes of pituitary enlargement.

Pediatric Myxedema Due to Autoimmune Hypothyroidism: A Rare Complication of a Common Disorder.

In children, hypothyroidism usually presents non-specific symptoms; symptoms can emerge gradually, compromising a timely diagnosis. We report the case of a 13-year-old male, who was admitted to the hospital due to swelling of the torso and neck. Besides these symptoms, the child was healthy, except for a significant growth delay. Ultrasound evaluation and blood tests led to the diagnosis of myxedema secondary to severe hypothyroidism, which was due to autoimmune thyroiditis. Further investigations revealed pericardial effusion and pituitary hyperplasia, with hyper-prolactinemia. Treatment with levothyroxine led to edema regression and clinical, hemato-chemical and radiological improvement. After 6 months, growth velocity increased, although the recovery of growth already lost was not guaranteed. Brain MRI showed regression of pituitary hyperplasia. The diagnostic delay in this case was probably due to the patient's apparent good health, and the underestimation of growth restriction. This report underlines the importance of growth monitoring in adolescence, a critical period for identifying endocrine conditions; if undiagnosed, these conditions can lead to serious complications, such as myxedema in hypothyroidism, with potential effects beyond growth on multiple organs.

Inadequate gonadal replacement in patients with Turner syndrome may result in pituitary volume enlargement.

OBJECTIVES: Patients with Turner syndrome need hormone replacement therapy for puberty induction. However, it is not known whether inadequate hormone replacement therapy affects the pituitary. DESIGN AND PATIENTS: Patients with Turner syndrome (n=35) and healthy control (n=20) (age/gender matched) subjects were included. MRI imaging of the pituitary was used to calculate pituitary volumes. According to the estradiol regimen, patients were divided into two groups; (i) those treated with low-dose conjugated oestrogen (CE, 0.625 mg) and (ii) those treated with combination therapy (ethinyl estradiol+sipropterone acetate; 35 mcg/2 mg). Pituitary measurements were calculated according to pituitary borders and their distances to each other via pituitary MRI. RESULTS: Pituitary hyperplasia (0.58±0.15 cm3 vs. 0.40±0.17 cm3) was determined in patients with low dose conjugated estrogen compared to the other patients or healthy control subjects (0.42±0.16 cm3) (p=0.005). Serum FSH levels of the patients treated with low dose CE were also higher compared to the patients who received combination therapy (p=0.001). CONCLUSION: Inadequate hormone replacement therapy can cause devastating effects on the bones and uterine health and disrupts the pituitary structure.

Pituitary Macroadenoma Secondary to Congenital Hypothyroidism With Growth Failure and Developmental Delay: A Rare Presentation.

Reactive pituitary hyperplasia can develop as a pituitary (pseudo) macroadenoma in the case of primary hypothyroidism. Hypothyroidism-induced pituitary hyperplasia (PHPH) can be managed medically. Surgery should not be performed if this condition is misdiagnosed as an adenoma. Primary hypothyroidism is a well-known cause of children's slow linear growth. Anterior pituitary enlargement is a rare symptom of severe or long-term illness (pituitary pseudotumor). Thyroid-stimulating hormone-secreting adenomas (TSHomas) are the rarest type of pituitary adenomas, with most endocrinologists seeing just a few cases throughout their lives. In most situations, the diagnosis is difficult, and patients may be referred after presenting with a condition of excessive thyroid-stimulating hormone secretion or a pituitary tumor. In this case study, we describe a 3.5-year-old girl who was referred to our hospital for a surgical assessment of a suspected pituitary neoplastic lesion. It was later determined that the suspected lesion was really pituitary hyperplasia brought on by primary hypothyroidism. Levothyroxine was started, and the dose was increased. The patient was advised to follow up to see if pituitary macroadenoma had responded to levothyroxine supplementation. Pituitary enlargement (pseudotumor of the pituitary gland) is a rare complication of primary hypothyroidism. Early diagnosis and treatment are critical for children with severe primary hypothyroidism to maintain their final height, as late diagnosis nearly always leads to a decline in adult stature. Pituitary macroadenoma secondary to severe hypothyroidism does not need risky and expensive surgical intervention. Because PHPH is rare in children, more credible information is needed to have a better knowledge of how the disease progresses and to develop scientific diagnostic criteria.

Long-Term Follow-Up Over 16 Years for Pituitary Hyperplasia Due to Primary Hypothyroidism With Positive Thyroid Stimulation Blocking Antibody: A Case Report.

Primary hypothyroidism is a known risk factor for pituitary hyperplasia, which develops symptoms due to compression of the optic chiasma and increased intracranial pressure. As pituitary hyperplasia is known to improve after levothyroxine replacement therapy, there are no reports of a long clinical course of pituitary hyperplasia due to primary hypothyroidism. We describe a case of follow-up over 16 years for pathologically diagnosed pituitary hyperplasia due to primary hypothyroidism with positive thyroid stimulation blocking antibody. Repeated enlargement and shrinkage were confirmed, but observations also suggested that the pituitary gland did not always return to normal size.

Hashimoto's thyroiditis, vitiligo, anemia, pituitary hyperplasia, and lupus nephritis-A case report of autoimmune polyglandular syndrome type III C + D and literature review.

Objective: This study aims to summarize the clinical characteristics of one teenager with autoimmune polyglandular syndrome (APS) type III C + D to improve the understanding of APS III C + D and its effect of thyroid function. Methods: This article reported the clinical manifestations, laboratory examinations, treatment methods, and outcomes of an adolescent with anemia admitted to the Pediatrics Department of Tianjin Medical University General Hospital in July 2020 and reviewed the literature. Results: A girl, aged 13 years and 1 month, was admitted to the hospital due to anemia for more than 4 years and episodic abdominal pain for 1 week. Four years ago, the girl went to a local hospital for "vitiligo", and a routine blood test revealed anemia. The lowest hemoglobin (HGB) was 61 g/L, and the blood test revealed iron deficiency anemia. She had no menstrual cramps for 2 months. Urine routine showed protein 3+∼4+ and 258 red blood cells (RBCs)/high-power field. Urine protein was 3,380 mg/24 h. Free thyroxine was low, thyroid-stimulating hormone was >100 uIU/ml, thyroid peroxidase antibody was >1,000 IU/ml, and thyroglobulin antibody and thyrotropin receptor antibody were negative. Pituitary magnetic resonance imaging showed a mass in the sellar region with a uniform signal and a maximum height of about 15.8 mm. The result of the antinuclear antibody was 1:80 homogeneous type, and anti-dsDNA and anticardiolipin antibodies IgA and IgM were slightly higher. Thyroxine and iron were given for 1 month, menstruation resumed, and urine protein and RBC count decreased. After 5 months of treatment, free thyroid function, HGB, RBCs in urine, and pituitary returned to normal. Later, a renal biopsy showed changes in focal proliferative glomerulonephritis, and the girl was diagnosed with lupus glomerulonephritis type III. After 3 days of shock therapy with methylprednisolone, prednisone, mycophenolate mofetil, and other treatments were administrated for 1 year. At the time of writing, urine protein was 280 mg/24 h. Conclusion: Co-occurrence of Hashimoto's thyroiditis, vitiligo, anemia, pituitary hyperplasia, and lupus nephritis is rare. It is very important to pay attention to the screening of thyroid function.

Van Wyk-Grumbach syndrome and trisomy 21.

The Van Wyk-Grumbach syndrome (VWGS) is characterized by severe hypothyroidism, peripheral precocious puberty, delayed bone age, hyperestrogenism, prepubertal luteinizing hormone, and elevated follicle-stimulating hormone. Patients with Down syndrome have a high susceptibility and prevalence of thyroid disorders. However, the coexistence of VWGS and trisomy 21 is uncommon. We present a case of a 5-year-old Mexican girl with Down syndrome, severe autoimmune hypothyroidism, pituitary enlargement, hyperprolactinemia, peripheral precocious puberty, multiple ovarian cysts, and delayed bone age, with a clinical diagnosis of VWGS. The patient presented with a remission of these manifestations after treatment with levothyroxine. Patients with Down syndrome, precocious puberty, hyperestrogenism, prepuberal luteinizing hormone, high follicle-stimulating hormone, and delayed bone age should be evaluated with a thyroid profile due to the possibility of VWGS.

Acromegaly Caused by Ectopic Growth Hormone Releasing Hormone Secretion: A Review.

Introduction: Ectopic acromegaly is a rare condition caused most frequently by growth hormone releasing hormone (GHRH) secretion from neuroendocrine tumors. The diagnosis is often difficult to establish as its main symptoms do not differ from those of acromegaly of pituitary origin. Objectives: To determine most common clinical features and diagnostic challenges in ectopic acromegaly. Patients and Methods: A search for ectopic acromegaly cases available in literature was performed using PubMed, Cochrane, and MEDline database. In this article, 127 cases of ectopic acromegaly described after GHRH isolation in 1982 are comprehensively reviewed, along with a summary of current state of knowledge on its clinical features, diagnostic methods, and treatment modalities. The most important data were compiled and compared in the tables. Results: Neuroendocrine tumors were confirmed in 119 out of 121 patients with histopathological evaluation, mostly of lung and pancreatic origin. Clinical manifestation comprise symptoms associated with pituitary hyperplasia, such as headache or visual field disturbances, as well as typical signs of acromegaly. Other endocrinopathies may also be present depending on the tumor type. Definitive diagnosis of ectopic acromegaly requires confirmation of GHRH secretion from a tumor using either histopathological methods or GHRH plasma concentration assessment. Hormonal evaluation was available for 84 patients (66%) and histopathological confirmation for 99 cases (78%). Complete tumor resection was the main treatment method for most patients as it is a treatment of choice due to its highest effectiveness. When not feasible, somatostatin receptor ligands (SRL) therapy is the preferred treatment option. Prognosis is relatively favorable for neuroendocrine GHRH-secreting tumors with high survival rate. Conclusion: Although ectopic acromegaly remains a rare disease, one should be aware of it as a possible differential diagnosis in patients presenting with additional symptoms or those not responding to classic treatment of acromegaly.

First Episode Psychosis and Pituitary Hyperplasia in a Patient With Untreated Hashimoto's Thyroiditis: A Case Report.

This case report describes a woman with no psychiatric history and previously diagnosed Hashimoto's thyroiditis who presented to the psychiatric emergency department with a first episode of psychosis. The initial workup for organic causes of psychosis revealed an astronomically high thyroid stimulating hormone (TSH) (> 1,000 µIU/mL) out of proportion to the patient's minimal physical symptoms of hypothyroidism. Additionally the patient's head imaging showed an enlarged pituitary, a rare, but reversible, presentation of chronically untreated primary hypothyroidism. The patient was transferred to a medical unit to receive IV thyroid hormone replacement as well as an adjunctive antipsychotic to assist with remission of her distressing auditory hallucinations and persecutory delusions. This case highlights the importance of a thorough medical workup for causes of new onset psychosis and the need for further consensus in the literature regarding choice of antipsychotic and duration of treatment for psychosis secondary to hypothyroidism.

Pituitary hyperplasia due to Himalayan endemic hypothyroidism.

Pituitary hyperplasia due to hypothyroidism can be treated medically. This condition should not be mistaken for adenoma and surgery should be avoided.

Sellar Gangliocytoma: Case Report and Review of an Extremely Rare Tumour.

Sellar gangliocytomas (SGs) are rare, well-differentiated, low-grade neoplasias that commonly present along with a pituitary adenoma (PA). We describe a case of a 52-year-old woman with a 2-year history of headache, body weight increase, and recent onset of arterial hypertension and type 2 diabetes mellitus. Work-up tests revealed a normal hypophyseal profile, except for mild ACTH elevation, and a sellar mass on magnetic resonance imaging (MRI). A diagnosis of an enlarging pituitary macroadenoma was established, and to prevent symptom progression, the tumour was resected. Pathology showed 2 cell populations: ganglion and corticotrope cells. Three years after surgery, the patient no longer had a headache but persisted with arterial hypertension and type 2 diabetes mellitus. A literature review produced 207 cases of SGs. They typically present in women at 40 years of age and the most common clinical presentation are symptoms of acromegaly. Of the documented cases, 74 and 93% were treated with surgery alone or combined treatments (radiotherapy, radiosurgery, or pharmacotherapy), respectively. The majority of deaths associated with a SG came from the first half of the 20th century. In conclusion, this patient presented with a silent SG with likely pituitary hyperplasia. SGs are a challenging diagnosis, have a benign course, and may provide insights into PA tumourigenesis.