Combined endoscopic and pharmacologic treatment of a suprasellar arachnoid cyst associated with macroprolactinoma
Jean-Yves Fournier, Stefan Bilz, Kathrin Schimke, Ina Krull, Jan Tasman, Michael Braendle & Gerhard Hildebrandt
A 58-year-old male patient presented with a 2 months history of bilateral frontotemporal headache, fatigue and impaired vision. Further exploration revealed short term memory losses, confusion, gait disturbances, decreased libido and erectile dysfunction. Radiological investigation showed a 4 cm pituitary mass with destruction of the upper clivus and left petrous apex associated with a 5 cm large suprasellar cyst bulging upward into the 3d ventricle with obstruction hydrocephalus. The greatly elevated prolactin level of 11 660 μg/l (Norm<25 μg/l) led to the diagnosis of a macroprolactinoma associated with a suprasellar arachnoid cyst. Incomplete homonymous quadrantanopia was disclosed by the ophthalmologic examination. The further endocrine work-up showed hypogonadotropic hypogonadism with intact remaining pituitary axes.
In a first stage the acutely symptomatic obstructive hydrocephalus was treated with an endoscopic fenestration of the arachnoid cyst through a frontal burrhole leading to immediate relief of the headache and gait disturbances. Treatment with cabergoline (2 mg weekly) led to a decrease of the serum prolactin to 330 μg/l within 6 weeks. Because of the persistence of the visual fields defects and the impeding CSF fistula an endoscopic transsphenoidal resection of the adenoma with a closure of the cranial base using the HadadBassagasteguy pedicled nasoseptal flap was performed.
Postoperative MR imaging showed a nearly complete resection with a decompression of the optic chiasm and resolution of the obstructive hydrocephalus without the need for a shunt device implantation. Upon continued treatment with cabergoline for 6 months the serum prolactin decreased to normal range with an increase of the testosterone to the normal range (8 nmol/l) and the other pituitary axes remaining intact. The visual field defects remained unchanged. The patient had an excellent recovery and returned to normal work.
This case illustrates a combined endoscopic neurosurgical and pharmacological treatment approach to an invasive macroprolactinoma associated with a large suprasellar arachnoid cyst with symptomatic obstructive hydrocephalus with an excellent result.