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14-FEBRUARY-2009  AYDA ABDEL-RAOOF BAKEER  47 YEARS  GIANT CRANIOPHARYNGIOMA MIMICKING PITUITARY ADENOMA WITH MASSIVE SUPRA AND PARASELLAR EXTENSION.

Anamnesis:

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The patient was transferred from Amman Surgical Center with clinical picture of giant pituitary adenoma.

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The patient started to complain of loss of vision in the right eye fro 18 months. The last 10 days got deterioration of vision of the left eye with lagophthalm and complete paralysis of the left eye. She had attacks of vomiting due to hypertensive-encephalic syndrome.

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On examination: the patient is practically blind in the right eye with light perception of the left eye. Complete paralysis of the left oculomotor nerve.

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MRI of the brain done 11-February-2009 showing giant pituitary adenoma with massive suprasellar and bilateral parasellar extension.

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Bilateral subfrontal approach was performed, with reflection of the bony flap to the left.

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The dura was opened parallel to the inferior bony defect and the SSS was coagulated at the most proximal part, preserving during that all the draining veins. Mobilization of the olfactory tracts was performed from under the mideo-basal parts of the frontal lobe down to the trigones. The tumor was pushing both optic nerves laterally and they were of long type. The tumor was attacked at the middle of the tuberculum sella and gradual debulking was achieved. The left side of the tumor was attacked first and the left optic nerve became lax. The right optic nerve was severely compressed by the tumor and resection of the tumor was achieved after further debulking. The suprasellar part was then removed after sharp dissection of the mass from the chiasm and mediobasal frontal lobe. All the suprasellar part was brought down and subsequently removed. After removal of the right parasellar extension, the right optic nerve became free and it was possible to see the right oculomotor nerve and the basilar artery.

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Inspection of the pituitary stalk, showed that it was tumorous and there was no connection to viable pituitary gland. It was decided to resect the pituitary stalk at the tumor involvement. All the vascular structures were preserved and no vascular injury took place at any stage of the operation.

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The frontal lobes were looking normal ruling out any surgical trauma.

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The patient was weaned and sent to the ICU.

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The patient final histological result was craniopharyngioma. It is retrospectively arising from the middle of pituitary stalk destroying all the pituitary gland.

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The patient still in the ICU 19-February-2009 with clinical picture of severe apathic syndrome with left hemiparesis. The vital signs are all the time stable and she was in Nimotop to decrease the arterial vasospasm and hormonal replacement therapy. She did not showed signs of diabetes insipidus and several control CT-scan were acceptable.

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The patient in 23-February-2009 at 1.15 P.M. during ambulation progressed massive pulmonary embolism with cardiac arrest  and several attempts to recover the cardiac function failed and brain death confirmed at 2.30 P.M.

Comments

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It is the usual practice to preserve the pituitary stalk and the pituitary gland during such operation, but when the tumor is invading the pituitary stalk as in this case, total tumor resection mandate the resection of the tumorous stalk with the rest of the tumor.

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After such procedure hormonal replacement therapy must be considered after surgery.

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Despite the anatomical preservation of the olfactory apparatus, only in 85% of cases recover their olfaction. For more details about craniopharyngiomas click here!.

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The patient is obese and she was covered with anticoagulants to avoid such event as pulmonary embolism. Despite this fact, she progressed this catastrophic event and we lost the patient.

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In major surgeries, the cause of death is pulmonary embolism and figuring first. Most of the patients rarely die in the operating table. They die when they start to ambulate. It was impossible to ambulate the patient early, because she was practically blind and obese and apathic. When she start to show improvement, the thrombotic phenomena started their storm.

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