PMC5672642_01
(a) Noncontrast head CT shows a heterogeneously hyperdense mass in the suprasellar cistern. (b) Sagittal T1-weighted brain MRI shows a large, partially cystic lesion without contrast, and (c) no enhancement with contrast. A small cystic lesion is seen in the pituitary gland (arrow). (d) Sagittal T2-weighted brain MRI demonstrates heterogenous signal in the lesion. Areas of low signal superiorly (arrow) are consistent with susceptibility effects suggesting hemorrhagic products. (e, f) Postoperative noncontrast head CT (e) and brain MRI (f) demonstrate gross total resection of the lesion
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F1
Noncontrast head computed tomography (CT) revealed a hyperdense, suprasellar, and third ventricular lesion, consistent with either intralesional microcalcifications or hemorrhage [Figure 1a]. A small intrasellar component of the lesion was also suspected [Figure 1b-d]. Five days later, the patient underwent bifrontal craniotomy and gross total resection of the suprasellar and third ventricular lesion via an interhemispheric transcallosal interforniceal approach [Figure 1e and f].
(a) Microphotograph of sellar lesion shows fibrotic adenohypophyseal tissue with scant strip of benign nonciliated columnar epithelium (hematoxylin-eosin, x130). (b) Intraoperative smear of specimen shows numerous cohesive clusters of benign squamoid epithelium with macrophages (hematoxylin-eosin, x120). (c) Microphotograph demonstrates hemorrhage and fibrin with hemosiderin-laden macrophages and fragments of benign tissue (hematoxylin-eosin, x50). (d) Immunohistochemical staining highlights abnormal vascular channels, consistent with a vascular malformation (CD31 stain, x50)
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F2
This was most consistent with the diagnosis of RCC, although a colloid or pars intermedia cyst or even a CP could not be ruled out [Figure 2a]. Pathologic examination of the specimen revealed abnormal ectatic vascular channels in a hemorrhagic background, consistent with a vascular malformation [Figure 2b-d].
(a and b) Noncontrast head CT following postoperative neurological worsening shows a right hemispheric subdural fluid collection with mass effect and midline shift. (c) Noncontrast head CT after evacuation of the subdural collection and right frontal EVD placement shows improvement in mass effect and midline shift. (d and e) Non-contrast head CT, 3 weeks later, shows recurrence of the right subdural hygroma with concomitant ventriculomegaly, consistent with external hydrocephalus. (f) Non-contrast head CT after permanent CSF diversion shows reduction in subdural collection size and mass effect
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F3
Head CT revealed a new right hemispheric subdural fluid collection with mass effect and midline shift to the left [Figure 3a and b]. The patient was thus taken to the operating room and underwent emergent evacuation of the subdural collection and placement of a left frontal external ventricular drain (EVD) [Figure 3c]. Head CT demonstrated external hydrocephalus [Figure 3d and e]. She was taken back to the operating room and underwent EVD placement, which was subsequently converted to a ventriculoperitoneal shunt a few days later [Figure 3f].