- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan
Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan
DOI:10.4103/2152-7806.139377Copyright: © 2014 Kinoshita Y. 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.
How to cite this article: Kinoshita Y, Tominaga A, Usui S, Kurisu K. A craniopharyngioma with spontaneous involution of a gadolinium-enhanced region on magnetic resonance imaging. Surg Neurol Int 20-Aug-2014;5:128
How to cite this URL: Kinoshita Y, Tominaga A, Usui S, Kurisu K. A craniopharyngioma with spontaneous involution of a gadolinium-enhanced region on magnetic resonance imaging. Surg Neurol Int 20-Aug-2014;5:128. Available from: http://sni.wpengine.com/surgicalint_articles/a-craniopharyngioma-with-spontaneous-involution-of-a-gadolinium-enhanced-region-on-magnetic-resonance-imaging/
Background:It has not been reported previously that the solid enhancing portion of a craniopharyngioma has involuted without a change in cyst size.
Case Description:We herein report a case of a craniopharyngioma with spontaneous involution of a solid gadolinium (Gd)-enhanced region on magnetic resonance imaging (MRI). A 44-year-old female was referred to our department with a mass on MRI associated with headaches and polyuria. The images showed a suprasellar cystic lesion progressing from the posterior pituitary lobe to the right hypothalamus along the pituitary stalk. Examinations of the cerebrospinal fluid showed aseptic meningitis and a positive titer of beta-human chorionic gonadotropin (HCG-β) preoperatively. The hypothalamic lesion became enlarged over the following 3 weeks, and a biopsy of the posterior pituitary lobe was performed via the endonasal transsphenoidal approach under a preoperative diagnosis of a germ cell tumor (GCT). The histological diagnosis was a craniopharyngioma, and the patient's postoperative findings on MRI were atypical: The solid Gd-enhanced region in the hypothalamus had spontaneously decreased in size and the peritumoral edema had improved, although the biopsy site in the posterior pituitary lobe was distant from the area of shrinkage. We speculated that the involutional portion on MRI mimicking a tumor was actually the normal hypothalamus, which was abnormally enhanced due to a disruption of the blood-brain barrier caused by the craniopharyngioma.
Conclusion:Gd-enhanced regions of parenchyma neighboring the cysts of craniopharyngioma should be carefully managed, taking into consideration the possibility of the enhancement of normal tissue.
Keywords: Craniopharyngioma, HCG-β, involution, inflammation, meningitis
Craniopharyngiomas can spontaneously decrease in volume due to a rupture of the cyst.[
A 44-year-old female was referred to our department with a suprasellar mass on MRI associated with headaches and polyuria. A neurological examination showed bitemporal lower quadrantanopsia. Endocrinological tests revealed disturbances in the secretion of ACTH, TSH, LH, and FSH and diabetes insipidus (DI). MRI demonstrated an intra- and suprasellar cystic lesion appearing as an iso-/low-intensity region on a T1-weighted image (WI) and an iso-/high-intensity region on a T2-WI [Figure
Initial coronal (a-c) and sagittal (d) magnetic resonance imaging results showing a cystic tumor in the right hypothalamus, pituitary stalk and posterior pituitary lobe as a low-/iso-intensity area on a T1-weighted image (a) and an iso-/high-intensity area on a T2-weighted image (b), with enhancement on T1-weighted images following gadolinium injection (c and d). An edematous area was observed in the right hypothalamus on the T2-weighted image (b). Preoperative Gd-enhanced coronal (e) and sagittal (f) T1-weighted images obtained 3 weeks after the initial examination showing an enlarged lesion infiltrating into the right hypothalamus
The lesion had become enlarged, infiltrating the hypothalamus by 3 weeks after the initial MRI study [Figure
The tumor exhibited an atypical postoperative course in that [Figure
Gd-enhanced coronal (a) and sagittal (c) T1-weighted images obtained 6 days after the biopsy showing involution of the Gd-enhanced lesion in the right hypothalamus. The edema in the right hypothalamus persisted on a coronal T2-weighted image (b). Two months after the biopsy, Gd-enhanced coronal (d) and sagittal (f) T1-weighted images showing further involution of the Gd-enhanced lesion in the right hypothalamus with an improvement in the edema on a coronal T2-weighted image (e)
In the present case, the titer of HCG-β was positive in the CSF and the tumor seemed to infiltrate into the intraaxial hypothalamus within a short period on preoperative MRI. Moreover, the Gd-enhanced region in the hypothalamus exhibited spontaneous involution with an improvement in the perifocal brain edema after the biopsy of the posterior pituitary lobe. These findings were confusing with respect to our management of the tumor based on the histological results of the biopsy.
HCG-β is a well-known useful tumor marker for GCT.[
The spontaneous involution of craniopharyngiomas has been reported in literature.[
We herein reported an atypical case of a craniopharyngioma showing the spontaneous involution of a Gd-enhanced region in the hypothalamus on MRI. We speculate that the features observed in this case were not due to shrinkage of the craniopharyngioma itself, but rather improvements in abnormally enhanced hypothalamic tissue neighboring the craniopharyngioma. Gd-enhanced regions of parenchyma neighboring the cysts of craniopharyngioma should be carefully managed, taking into consideration the possibility of the enhancement of normal tissue.
The content of this manuscript has not been published in full elsewhere in any form. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
This work was supported in part by Research Grants from the Ministry of Education, Culture, Sports, Science and Technology of Japan.
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