Pituitary Tumor
Patient Presentation:
D.A., a 46 year old female presented to an OSH complaining of recent gait ataxia, blurry vision, bilateral temporal hemianopsia, dizziness, and intermittent headache. She has a known history of a “brain tumor” and HTN. She did not complain of N/V, numbness or tingling in extremities, recent weight loss/gain, or history of falls.
Differential List: (if she had not known of brain tumor already)
Stroke
Brain tumor pressing on her optic chiasm
Diagnosis:
After performing a head CT without contrast at the OSH, a brain tumor was seen and the patient was sent to the Neuro ICU at a local hospital for further workup and treatment. Here, a MRI of the brain with and without contrast was done. A large mildly hyper dense mass in the sella turcica and suprasellar region measuring 6.2 x 5.3 cm was found. No hydrocephalus or acute hemorrhage was found. In the MRI, the optic chiasm was not visualized, most likely being covered or displaced by the mass. Based on the location of the tumor visualized on the CT and MRI, the tumor is most likely to be a pituitary adenoma. A CBC and Chem-10 were all WNL.
Treatment:
D.A. was started on Decadron® 4mg q 6 hours IV for swelling. She was also started on 25mg Lopressor® q 8 hours IV for hypertension. She underwent a right frontoparietal craniotomy for partial resection of the tumor (surgery done in two parts due to the large size of the mass) and placement of an EVD to help drain CSF. She was admitted back to the Neurosurgery ICU for stabilization. Steroids were continued and electrolytes were replaced daily. A day 1 post-op head CT showed mild pneumocephalus and a small hemorrhage at the site of tumor resection. The patient was somnolent and not speaking. A few days later, she was speaking but confused. She would not answer orientation questions or follow commands. One week later, she was taken back to the OR for a left frontal craniotomy for resection of the remaining tumor. She was brought back to the ICU, intubated. A post-op head CT showed a new large hemorrhagic region in the left frontal lobe with an 11 mm left-to-right midline shift. Trace intraventricular hemorrhage was visible. Slight hydrocephalus (enlargement of brain ventricles) was seen. Evolving areas of edema in the right frontal and temporal regions were seen. Her neuro status worsened. She was obtunded, not opening her eyes, and no spontaneous movement. She was not on sedation. Head CTs were done almost daily to track the stability of her condition. Evolving right basal ganglia and thalamic infarcts were seen. Her ICP was very high (around 40 mm Hg; less than 20 mm Hg is normal) so she was paralyzed with vecuronium and pentobarbital, and she underwent a left frontoparietal decompressive craniectomy (removal of the bone flap) to allow the brain parenchyma to swell and expand. A post-op head CT without contrast showed upward and downward cerebellar herniation and right-to-left herniation. D.A.‘s vent settings were increased to an FiO2 of 100% on CMV due to desaturation (SaO2 of 90%). D.A. was dumping light urine (approximately 500-700 ml per hour) and diabetes insipidus labs were sent. She was confirmed to be in DI with a urine spec grav of 1.001 (normal is 1.003 - 1.030) and a serum osmo 368 mOsm/kg (normal is 275 - 300 mOsm/kg). A lack of ADH production is seen with pituitary tumors. She received doses of DDAVP (vasopressin analogue) and her urine output was replaced with 0.9% Normal Saline 1:1. She was started on broad spectrum antibiotics for treatment of elevated WBC (21.0).
Outcome:
D.A.’s daughter was told about her mother’s worsening status. D.A. failed an apnea test (to see if a pt will have a drive to breath on her own without the ventilator, confirming breath death). Twenty-four hours after confirmed brain death, the endotracheal tube was removed and D.A. soon expired.