- Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
DOI:10.4103/2152-7806.72624© 2010 Mittal P 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: Mittal P, Dua S, Saggar K, Gupta K. Magnetic resonance findings in sellar and suprasellar tuberculoma with hemorrhage. Surg Neurol Int 20-Nov-2010;1:73
How to cite this URL: Mittal P, Dua S, Saggar K, Gupta K. Magnetic resonance findings in sellar and suprasellar tuberculoma with hemorrhage. Surg Neurol Int 20-Nov-2010;1:73. Available from: http://sni.wpengine.com/surgicalint_articles/magnetic-resonance-findings-in-sellar-and-suprasellar-tuberculoma-with-hemorrhage/
Background:Tuberculosis is endemic in many counteries like India. It can infect any site in the central nervous system. However, islolated involvement of the sellar and suprasellar region is rare. Sellar tuberculoma with hemorrhage is even more rare. We present magnetic resonance (MR) findings in case of sellar and suprasellar tuberculoma with hemorrhage.
Case Description:A 40-year-old female patient presented with a 1-month history of persistent headache and blurred vision on the left side. A contrast-enhanced MR study revealed peripherally enhancing sellar and suprasellar mass with hemorrhage with compression of the left half of the optic chiasma. There was also evidence of infundibular thickening and enhancement of the adjacent dura. The mass was approached through a transphenoidal approach and was partially resected. Subsequent histopathology was suggestive of tuberculosis. The patient was put on anti-tubercular therapy. Patient reported significant improvement in symptoms. Follow-up MR done 8 months later confirmed complete regression of the mass.
Conclusion:Because of its rarity, sellar tuberculoma is seldom considered in the differential diagnosis and is often mistaken for pituitary macroadenoma, which is the most common tumor in this region. Although rare, presence of infundibular thickening and enhancement of the adjacent dura should suggest the presence of a granulomatous lesion like tuberculoma.
Keywords: Hemorrhage, MRI, sellar, tuberculoma
Intracranial tuberculosis is a common infection is India. However, involvement of the pituitary gland is very unusual. There are only isolated reports. To our knowledge, there are about 51 case reports of sellar tuberculosis.[
A 40-year-old female patient presented with persistent headache and blurring vision on the left side for 1 month. She had no history of trauma or menstrual complaints. She was on hormonal replacement therapy for thyroid hormone deficiency for 2 months. She had no history or evidence of tuberculosis elsewhere in the body. A contrast-enhanced magnetic resonance (MR) study was performed. A sellar mass with suprasellar extension was seen. It appeared isointense, with multiple hyperintense areas on T1W images. Suprasellar extension of the mass was bulging to the left of the midline and was causing compression of the left side of the optic chiasma [
Figure 2a and b
Sagittal post-contrast image showing rim enhancement (black arrow in a) in the mass. The adjacent dura also shows enhancement (white arrows in a and b). The inset shows a normal pituitary on the post-contrast images for comparison. The sagittal post-contrast image (b) shows a thickened and enhancing pituitary stalk (black arrow in b).
Sellar tuberculosis is a very rare infection. It was first described long back in 1940 by Coleman et al.[
Pituitary apoplexy is a condition characterized by acute neurological symptoms due to hemorrhage in the pituitary. Pituitary adenoma is the predominant cause in a large proportion of the cases, and most of these are non-functioning macroadenomas.[
On MR imaging, tuberculomas closely mimic pituitary adenoma. They present as a largely isointense mass on T1 and T2W images with heterogeneous areas. Uniform, heterogeneous as well as peripheral rim-like enhancement is described, the non-enhancing areas being attributed to caseation necrosis. Other findings that have been considered useful include thickening of the pituitary stalk and enhancement of the adjacent dura.[
Our index case showed a heterogeneous mass on T1W images with multiple hyperintense areas which bloomed on the GRE images, indicating hemorrhage. It was heterogeneous, predominantly hypointense on T2W images. On post-contrast images, it showed ring-like enhancement. The pituitary stalk was mildly thickened. The adjoining dura also showed enhancement. Although findings indicate the possibility of some granulomatous lesion, diagnosis of tuberculosis was not considered because of its rarity and due to the presence of the associated hemorrhage. A follow-up scan after surgery and antitubercular therapy showed that the mass had largely regressed. However, thickening of the pituitary stalk was still persistent, which has also been reported previously.[
It has been suggested that in any sellar mass with thickening and enhancement of the pituitary stalk, diagnosis of tuberculosis should be considered especially in places where tuberculosis is endemic. Thickening of the pituitary stalk can also be seen in other conditions like sarcoidosis, lymphocytic hypophysitis, lymphoma and eosinophilic granuloma.[
Hemorrhage in a sellar tuberculoma is extremely rare, with only two case reports in the literature.[
In conclusion, sellar tuberculoma is a rare condition and is difficult to diagnose on imaging. The presence of hemorrhage is even more atypical. Findings that can be useful in diagnosis include ring enhancement, thickening of the pituitary stalk and enhancement of the adjacent dura. These features can help one to consider the possibility of some granulomatous condition and guide further investigations to reach the correct diagnosis.
1. Ahmad FU, Chandra PS, Sanyal S, Garg A, Mehta VS. Sellar tuberculoma: An unusual infection. Indian J Tuberc. 2005. 52: 215-7
2. Arunkumar MJ, Rajshekhar V. Intrasellar tuberculoma presenting as pituitary apoplexy. Neurol India. 2001. 49: 407-10
3. Biousse V, Newman NJ, Oyesiku NM. Precipitating factors in pituitary apoplexy. J Neurol Neurosurg Psychiatry. 2001. 71: 542-5
4. Coleman CC, Meredith JM. Diffuse tuberculosis of the pituitary gland simulating tumor with postoperative recovery. Arch Neurol Psychiatry. 1940. 44: 1076-85
5. Deogaonkar M, De R, Sil K, Das S. Pituitary tuberculosis presenting as pituitary apoplexy. Int J Infect Dis. 2006. 10: 338-9
6. Desai KI, Nadkarni TD, Goel A. Tuberculomas of the hypophysis cerebri: Report of five cases. J Clin Neurosci. 2003. 10: 562-6
7. Kim SH, Kim DG. Sellar Tuberculoma Mimicking Pituitary Adenoma. J Korean Neurosurg Soc. 2003. 34: 245-8
8. Maccagnan P, Macedo CL, Kayath MJ, Nogueira RG, Abucham J. Conservative management of pituitary apoplexy: A prospective study. J Clin Endocrinol Metab. 1995. 80: 2190-7
9. Manghani DK, Gaitonde PS, Dastur DK. Pituitary tuberculoma--a case report. Neurol India. 2001. 49: 299-301
10. Rao S, Rajkumar A, Kuruvilla S. Sellar lesion: Not always a pituitary adenoma. Indian J Pathol Microbiol. 2008. 51: 269-70
11. Saini KS, Patel AL, Shaikh WA, Magar LN, Pungaonkar SA. Magnetic resonance spectroscopy in pituitary tuberculoma. Singapore Med J. 2007. 48: 783-6
12. Sharma MC, Arora R, Mahapatra AK, Sarat-Chandra P, Gaikwad SB, Sarkar C. Intrasellar tuberculoma--an enigmatic pituitary infection: A series of 18 cases. Clin Neurol Neurosurg. 2000. 102: 72-7
13. Singh S. Pituitary tuberculoma: Magnetic resonance imaging. Neurol India. 2003. 51: 548-50
14. Sunil K, Menon R, Goel N, Sanghvi D, Bandgar T, Joshi SR. Pituitary tuberculosis. J Assoc Physicians India. 2007. 55: 453-6
15. Tuna M, Erman T, Ildan F, Göèer AI, Zorludemir S, Haciyakupoglu S. Isolated sellar tuberculoma with a thickened pituitary stalk: Case report. Turk Neurosurg. 2001. 11: 142-5