Non-Hodgkin Lymphoma Causing Hypopituitarism Can Imaging Help Diagnosis and Management?

Non-Hodgkin lymphomas of the hypothalamus and pituitary are rare. They usually remain clinically silent until onset of compressive features affecting surrounding structures. When symptomatic, patients most commonly present with diabetes insipidus, headaches, ophthalmoplegia and/or bilateral hemianopia. We report a case of a 67-year-old Caucasian female with a history of B-cell lymphoma in complete remission. She presented with left oculomotor nerve palsy and was subsequently found to have a sellar/suprasellar mass lesion on MRI. Alongside hypocortisolism and hypogonadotropic hypogonadism, she developed transient diabetes insipidus during her illness. Her clinical course was characterized by rapid intracranial progression of the sellar mass. MR spectroscopy suggested a diagnosis of lymphoma. Diagnostic biopsy confirmed high-grade diffuse large B-cell CNS lymphoma; this changed the definitive management from surgical excision to chemotherapy. Despite treatment, she succumbed to her illness within 7 months of initial presentation. This case highlights the aggressive nature of CNS lymphomas and the need for a high index of suspicion in an unusual presentation of sellar/suprasellar mass lesions

Early Experience in the Treatment of Intra-Cranial Aneurysms by Endovascular Flow Diversion: A Multicentre Prospective Study

INTRODUCTION: Flow diversion is a new approach to the endovascular treatment of intracranial aneurysms which uses a high density mesh stent to induce sac thrombosis. These devices have been designed for the treatment of complex shaped and large size aneurysms. So far published safety and efficacy data on this approach is sparse. MATERIAL AND METHODS: Over 8 months, standardized clinical and angiographic data were collected on 70 patients treated with a flow diverter device (SILK flow diverter (SFD)) in 18 centres worldwide. Treatment and early follow up details were audited centrally. SFDs were deployed alone in 57 (81%) or with endosaccular coils in 10 (14%) aneurysms, which included: 44 (63%) saccular, 26 (37%) fusiform shapes and 18 (26%) small, 37 (53%) large, 15 (21%) giant sizes. Treatment outcome data up to 30 days were reported for all patients, with clinical (50 patients) and imaging (49 patients) follow up (median 119 days) data available. RESULTS: Difficulties in SFD deployment were reported in 15 (21%) and parent artery thrombosis in 8 (11%) procedures. Procedural complications caused stroke in 1 and serious extracranial bleeding in 3 patients; 2 of whom developed fatal pneumonias. Delayed worsening of symptoms occurred in 5 patients (3 transient, 1 permanent neurological deficit, and 1 death) and fatal aneurysm bleeding in 1 patient. Overall permanent morbidity rates were 2 (4%) and mortality 4 (8%). Statistical analysis revealed no significant association between complications and variables related to treated aneurysm morphology or rupture status. CONCLUSION: This series is the largest reporting outcome of the new treatment approach and provides data for future study design. Procedural difficulties in SFD deployment were frequent and anti-thrombosis prophylaxis appears to reduce the resulting clinical sequelae, but at the cost of morbidity due to extracranial bleeding. Delayed morbidity appears to be a consequence of the new approach and warrants care in selecting patients for treatment and future larger studies

Partially thrombosed aneurysm after treatment with the flow diverter.

<p>CT angiograms showing a residual lumen within a large partially thrombosed fusiform aneurysm of the middle cerebral artery. Follow-up CTA (a) was performed 4 months and (b) 6 months after SFD (arrows) placement. The second follow-up study shows enlargement of the residual aneurysm lumen (arrow heads) and was performed after a new haemorrhage (not shown).</p

Timings and results of angiographic follow up.

<p>Plot of angiographic outcomes against follow up times in weeks.</p

Effect of patient and procedure related variables on SFD deployment difficulty, flow disturbance, and delayed neurological complications.

<p>Untoward events reported during and after treatments related to aneurysm shapes, sizes location, and use of coils.</p><p>Deployment difficulty  =  poor opening, poor positioning, or migration of SFD.</p><p>Flow disturbance  =  partial or complete thrombosis of parent artery.</p

Angiographic outcomes for the aneurysms treated with SFD.

<p>Angiographic outcomes for the cohort of aneurysms with complete follow up i.e. end of treatment and follow up angiogram.</p><p>Abbreviations: OG1 (complete occlusion); OG2 (neck remnant); OG3 (saccular filling).</p

Clinical complications observed in patients treated with SFD.

<p>Abbreviations: BA (basilar artery), PcomA (posterior communicating artery), CCA (carotid cavernous artery), MCA (middle cerebral artery), AICA (anterior inferior cerebellar artery), COA (carotid ophthalmic artery), S (saccular), F (fusiform), EVT (endovascular therapy).</p