alexa Pituitary Adenoma Complicated by Hydrocephalus in a Patient Treated with Cabergoline | OMICS International
ISSN: 2161-1017
Endocrinology & Metabolic Syndrome
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Pituitary Adenoma Complicated by Hydrocephalus in a Patient Treated with Cabergoline

Ruben Van den Brande1,*, Pascale Abrams2and Tony Van Havenbergh3

1University of Antwerp, faculty of medicine and Health sciences, Universiteitsplein 1, 2610 Wilrijk, Belgium

2Department of Endocrinology, Sint-Augustinus Hospital, Oosterveldlaan 24, 2610 Wilrijk, Belgium

3Department of Neurosurgery, Sint-Augustinus Hospital, Oosterveldlaan 24, 2610 Wilrijk, Belgium

Corresponding Author:
Ruben Van den Brande
University of Antwerp
faculty of medicine and health sciences
Universiteitsplein 1, 2610 Wilrijk, Belgium
Tel: +32 478 54 72 67
E-mail: [email protected]

Received Date: November 02, 2015; Accepted Date: November 05, 2015; Published Date: November 09, 2015

Citation:Brande RVD, Abrams P, Havenbergh TV (2015) Pituitary Adenoma Complicated by Hydrocephalus in a Patient Treated with Cabergoline. Endocrinol Metab Syndr 4:205. doi:10.4172/2161-1017.1000205

Copyright: © 2015 Brande RVD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Endocrinology & Metabolic Syndrome

Abstract

We describe a 55 year old, female patient with known pituitary adenoma since 9 years who was lost to follow up during 8 years. She presented with temporal vision loss, no other complaints. Imaging showed a large sellar mass which expanded suprasellar with severe anterior displacement of the chiasma opticum and extending into the third ventricle with significant obstruction of the foramen of Monroe, leading to a dilatation of the right lateral ventricle. Clinical significant tumour progression occurred under treatment with Cabergoline, leading to hydrocephalus. Patient underwent semi urgent endoscopic transsphenoidal resection of the tumour. Three months after surgery the patient was asymptomatic and imaging confirmed a complete resection. Hormone levels where in normal range on account of the substitution therapy. This case stresses the importance of follow-up in patients with pituitary adenomas.

Keywords

Pituitary; Adenoma; Hydrocephalus; Cabergoline; Endoscopic surgery

Background

Pituitary adenomas can be an incidental finding on imaging or can present with neurological manifestations as a consequence of the mass effect or as a syndrome of hormone hyper secretion and/or deficiency [1-3].

Visual field deficits/decreased visual acuity (63.9%) and headaches (50.9%) are common symptoms in these cases. In contrast with headaches, visual disturbances tend to correlate with tumour size [4].

Neurological symptoms are more common in non-functioning adenomas because these tumours do not secrete sufficient hormones to cause endocrine-type symptoms. As a consequence the diagnosis is delayed until the patient presents with headaches or visual changes. Hydrocephalus as a complication of pituitary adenomas is infrequent. In the literature there are only a handful of case reports concerning this complication [5-12].

Case

A 55 year old woman with known pituitary adenoma since 2005 was lost to follow up from March 2007 until February 2015 because of anxiety of the patient. The last control Magnetic Resonance Image (MRI) was performed in 2006, the scan showed a macro adenoma with dimensions of 2.8x2.5 cm with a cystic and haemorrhagic component. At the time, the patient had no complaints of headaches, visual disturbances or other symptoms. Cabergoline treatment was initiated in June 2005 with 0,5 mg/day which was gradually augmented till 1 mg/ day (June 2006).

The patient received suppressive therapy with Cabergoline 1 mg a day during the 8 years of lost to follow up. She contacted the endocrinologist to plan a follow-up appointment by reason of complaints of temporal vision loss. The patient denied complaints of headaches, dizziness or gait disturbances. No complaints of frequent passage of large volumes of urine. A MRI of the pituitary and blood sample was planned.

Blood sample showed an elevated prolactine level of 188 μg/L, a depressed LH of < 0.2 U/L, a depressed FSH of 1,7 U/L and a cortisol deficiency ( 9.6 μg/dl).

The MRI showed a large sellar mass (3.1 cm × 2.3 cm × 2.6 cm) which expanded suprasellar with severe compression of the chiasma opticum and extending through the bottom of the third ventricle with significant obstruction of the foramen of Monroe, leading to a dilatation of the right lateral ventricle. The outflow obstruction of the right lateral ventricle resulted in transependymal migration of cerebrospinal fluid (CSF). The mass was hyper intense and partly iso-intense on T2, T1 showed a cystic and/or necrotic component.

Subsequently the patient was contacted to come to an urgent, combined consultation with the endocrinologist and neurosurgeon. A Compute Tomography (CT)-scan for neuro-navigation during surgery was executed. Three days after the MRI investigation, four hands endoscopic transsphenoidal pituitary adenomectomy was performed. After removal of the tumour we had an endoscopic view into the third ventricle with visualistaion of the foraminae of Monroe with the plexus choroideus, Sylvia aquaduct and a view in the dilated right lateral ventricle (Figure 1).

endocrinology-metabolic-syndrome-Pre-operative

Figure 1: 1 Pre-operative mid-sagittal T1 weighed, 2. Pre-operative midsagittal T2 weighed, 3. Pre-operative view inside the third ventricle, 4. Postoperative coronal T1 weighted.

Post-operative the patient was transferred to intensive care. Her stay in the Intensive Care Unit (ICU) was prolonged due to a bilateral pneumonia and liquor leakage. A lumbo-external drain was placed to control the liquor leakage. As the evolution was not favourable, a revision procedure with reconstruction of the sellar floor with cartilage and repositionoing of the nasoseptal flap was performed with success. The patient receives substitution therapy with L-Thyroxine 100 μg a day, hydrocortisone (20 mg - 10 mg – 10 mg a day) and nasal Desmopressine spray.

Microscopic examination of the biopsies confirmed the diagnosis of a non-secreting pituitary macroadenoma. One month postoperatively the patient was feeling good: no complaints of headaches, temporal vision improved with only discrete loss in the left eye. Blood analysis show good results of the substitution therapy which is continued (Hydrocortisone 10 mg - 10 mg - 10 mg a day) Table 1. Three months postoperatively a control MRI of the pituitary gland showed no arguments for residue or relapse tumour. The supratentorial ventricle system is widened and the chiasma opticum is descended into the sella turcica. Insuline tolerance test showed a cortisol deficiency, relatively high ACTH and a significant growth hormone deficiency. Consequently growth hormone substitution therapy was started with Somatropine 5,3 mg, 0,2 mg once a day.

Medication Pre-operative Post-operative 3 months post- operative Normal range
Cabergoline 1 mg/day Solu-cortef 50 mg 3x/day
Minirin Spray
L-thyroxine 100 µg
Hydrocortisone 20-10-10 mg
desmopressine Spray 10 µg
Prolactine (µg/L) 188 1.9 7.0 < 25
TSH (mU/L) / / <0.010 0.5-5.7
Free T4 (ng/dL) 0.85 0.62 1.24 0.8-1.8
Morning plasma Cortisol (µg/dL) 9.6 5.6 5.0 7-28
ACTH (pg/mL) 18 9.9 16 10-60
Growth hormone (µg/L) / / 0.070 < 8
Insuline-like growth factor (IGF)1 ng/ml 194 124 228 45-173

Table 1: Treacibility of the drug intake at different stages i.e. Pre-operative, Postoperative & 3 months post-operative period.

Discussion

This patient was treated with a high dose of cabergoline (1 mg a day) for multiple years. Under therapy, tumour progression continued until presentation even though cabergoline treatment is associated with minor tumour shrinkage [13,14]. This case demonstrates the importance of follow up in patients with pituitary adenomas. The association between tumour growth and the development of complaints is weak. This tumour gained volume until it compressed the optic chiasm before the patient presented herself to the doctor. At the moment of presentation, the tumour had a cystic, necrotic component. Imaging showed a dilatation of the ventricular system, right lateral ventricle more pronounced than the left. At the right side we could see transependymal migration of CSF on MRI. She had no other complaints besides temporal vision loss, however with the images from MRI we would suspect more clinical symptoms. We assume that the patient came just in time and that every day of delay for surgery increased the risk of major complications following the hydrocephalus [15].

Lessons to be learned from this case are (I) the importance of regular follow up in patients with pituitary adenomas, (II) the weak association between radiologic findings and clinical symptoms in patients with pituitary adenomas and (III) that even large tumours can be removed through an endoscopic trans nasal transsphenoidal surgery.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

Article Usage

  • Total views: 8066
  • [From(publication date):
    December-2015 - Dec 15, 2017]
  • Breakdown by view type
  • HTML page views : 7993
  • PDF downloads : 73
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version