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Images in Neurology
August 2007

Massive Sellar and Parasellar Schwannoma

Arch Neurol. 2007;64(8):1198-1199. doi:10.1001/archneur.64.8.1198

A 41-year-old Middle Eastern man presented with a tingling sensation on the right side of his face that had started 4 years earlier. At that time, there was no evidence of sensory loss on physical examination and his physician prescribed natural honey. His symptoms partially resolved, but in the past year and a half he began to experience difficulties with vision in his left side. An ophthalmologic examination demonstrated a bitemporal hemianopsia. No symptoms of endocrine dysfunction were noted. A computed tomographic scan revealed a large sellar-based mass, which prompted referral to our institution. His medical and family histories were noncontributory. On neurologic examination there was mild optic pallor, mild nystagmus with abduction, and slight fourth and sixth cranial nerve weakness. Pituitary hormone levels were normal except for a borderline increase in prolactin and a decrease in insulinlike growth factor 1. Magnetic resonance imaging showed a multilobated, cystic, 7 × 6-cm enhancing mass expanding the sella turcica and extending into the prepontine cistern and the cavernous sinuses bilaterally, extension on the right cavernous sinus greater than on the left (Figure, A and B). The radiologic differential diagnosis included pituitary macroadenoma and craniopharyngioma. The patient was taken to surgery and underwent a right pterional craniotomy with debulking of approximately 80% of the mass. Intraoperatively the tumor had a heterogeneous consistency. Findings from histologic examination showed a neoplasm characterized by bland spindle cells with oval nuclei arranged in short fascicles and frequent palisading (Figure, C). Hyalinized vessels with perivascular hemosiderin deposition and frequent macrophage aggregates were additional features. A diagnosis of schwannoma was made. Postoperatively the patient developed hyperglycemia, low thyrotropin levels, and hyponatremia, which were managed medically. He is slowly recovering.

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