PMC5224775_01
Magnetic Resonance (MRI) coronal image TSE - T1-weighted after administration of contrast material. In panel A, B, C, D, and E the images acquired in the first exam, after 2 months, after 7 months, after 14 months, and after 22 months, respectively, are given. The asterisks identify the carotid arteries in the supra-clinoid segment. In panel A, the caudal part of the infundibular stalk (white arrow) seems to be involved by the prolactinoma, whereas the optic chiasm does not show pathological signal (white arrowhead). There is also a complete encasement of the internal carotid artery. In the panel B, the infundibular stalk (white open arrow) does not show alteration, whereas in the panel C, a small (mm 3.2) hypointense mass with peripheral enhancement is observed; these are the typical features of a craniopharyngioma that become clearer in the panel D with a mass diameter of 5.7 mm and panel E with a mass diameter of 15.6 mm. In the panel E, the cranial dislocation of the optic chiasm is also visible (white open arrowhead). In the MRI check, acquired 2 months after the surgical procedure, there was no evidence of recurrence of pathology (panel F) but the herniation of the chiasmatic cistern into the sellar cavity is visible (white dashed line).
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A big (61 x 53 mm) mass with homogenous hyper-signal after the intravenous administration of contrast material was documented in the sellar area, including the caudal part of the infundibular stalk, without involvement of the optic chiasm (Fig. 1A). In the second MRI exam performed after 2 months, serum PRL was 1490 mIU/L (70.3 ng/mL), galactorrhea disappeared and a reduction in the volume of the prolactinoma was clearly visible (Fig. 1B); two months after, normal menses reappeared. From the third exam (performed after 7 months), besides further progressive reduction in the prolactinoma (serum PRL 496.1 mUI/L [23.4 ng/mL]), MRI revealed, in the infundibular stalk, a small round lesion with a homogenous hypointense signal on T1 sequences and enhanced peripherally after gadolinium; these are typical MRI features associated with a craniopharyngioma (Fig. 1C). During the two following MRI checks (14 months and 22 months), the stalk mass becomes larger reaching a diameter of 15.6 mm (from a value of 3.2 mm) with cranial dislocation of the optic chiasm (Fig. 1D and E). The MRI check performed 2 months after the surgical procedure (Fig. 1D and F) did not find any evidence of recurrence for both craniopharyngioma and prolactinoma, but showed a herniation of the chiasmatic cistern into the sellar cavity, which could be responsible for the incomplete recovery of visual field. This extremely uncommon condition was probably responsible for the delayed recognition of the craniopharyngioma image, which was detectable several months before the onset of visual field loss (Fig. 1C and D) and whose detection could have allowed earlier surgical removal.
PMC5224775_02