An Unusual Intracranial Inflammatory Process of Unknown Origin

Abstract

We present an unusual case of steroid responsive inflammatory condition, involving sellar suprasellar region with further ependymal lesions. This is complicated by previous surgery due to pituitary adenoma, not thought to related to inflammatory process. The patient responded well to steroids, but deteriorated due to development of hydrocephalus caused by obstruction due to adhesions. Despite extensive literature review and consideration of all known pathological conditions, it was concluded that the condition represented another inflammatory entity not yet fully characterised. The case also highlights that despite the steroid responsive nature of the condition, the ependymal involvement can result in progressive acute obstructive hydrocephalus with clinical deterioration. This case also suggests close follow-up and early imaging for early detection and treatment of this complication. CASE REPORTThis case report pertains to a 46-year-old male Caucasian who had endoscopic treatment for a pituitary adenona three years previously. He required replacement hydrocortisone and testosterone. Prior to the surgery, he was not known to have any other neurological issues.A year after surgery following minor trauma, he underwent a computed tomography (CT) scan of the head. This confirmed no residual pituitary tumour (Figure 1). He was somewhat non-compliant with endocrine follow-up. Surveillance magnetic resonance imaging (MRI) imaging 2 years following initial surgery demonstrated post-up change with some enhancing tissue scaling the pituitary stalk and hypothalamic region; this was not clearly seen on the previous CT scan, possibly due to different modalities and absence of contrast imaging. Two months later, he developed polydipsia, fatigue and a partial left-sided homonymous visual field deficit. There was progressive confusion with fluent dysphasia and inattention. He was pyrexial. Gaze evoked nystagmus was present to the right. The rest of his examination was unremarkable. MRI brain demonstrated significant progression of the abnormalities seen on the earlier scan with increased enhancing tissue involving the pituitary stalk, hypothalamic area and floor of the 3 rd ventricle, also including the optic chiasm (Figure 2). Associated signal