I15149

- Chronic diseases:

1. Diabetes mellitus (DM)
2. Dyslipidemia (DLP)
3. Hypertension (HTN)
4. Diabetic retinopathy

- Relevant surgical history:

1. Cataract surgery in the right eye.

Chronic usual treatment:

- Ocular:

1. Xalatan (Latanoprost) 50mcg/ml eye drops: 1 drop in both eyes every 24 hours.
2. Cusimolol 5mg/ml eye drops: 1 drop in both eyes every 12 hours.
3. FML 1mg/ml eye drops: 1 drop every 6 hours.
4. Azopt 10mg/ml eye drops: 1 drop every 12 hours.

- Cardiovascular and metabolic:

1. Hipertene (Imidapril) 10mg: 1 tablet every 24 hours.
2. Atorvastatin 60mg: 1 tablet daily.

- Diabetes:

1. Novorapid Flexpen 100u/ml: 9 units with lunch and 9 units with dinner.
2. Lantus Solostar 100u/ml: 36 units at breakfast.

An 81-year-old male patient who was transferred - Scalp wound due to a fall.

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Complementary tests:

- CT scan of the brain and angiography of supra-aortic trunks and Willis polygon:

Findings:

1. Prominent subarachnoid spaces compatible with age-related involutional changes.
2. Proportional dilation of the ventricular system with no signs of activity or midline shift.
3. Hyperdense thickening of the falx cerebri suggestive of a laminar subdural hematoma.
4. Space-occupying lesion in the sella turcica (36 × 20 mm), to be evaluated with clinical history.

Conclusions:

1. Cerebral involutional changes.
2. Laminar subdural hematoma.
3. Lesion in the sella turcica suggestive of pituitary macroadenoma.
4. Willis polygon and supra-aortic trunks with no significant alterations.

- MRI of the pituitary with contrast:

Findings:

1. Pituitary macroadenoma measuring 31x18x30 mm with suprasellar extension, reaching the clivus and cavernous sinuses, with mass effect on the left temporal lobe.
2. Grade 4 anterior temporal atrophy, prominent for the patient's age.
3. Mild ischemic leukoencephalopathy due to small vessel disease.

Conclusion:

1. Pituitary macroadenoma.
2. Cortical-subcortical atrophy.
3. Mild ischemic leukoencephalopathy.

Diagnosis:

1. Pituitary tumor.

Solid mass of approximately 31x18x30 mm in longitudinal, anteroposterior, and transverse diameters, respectively, occupying the sella turcica with extension to the suprasellar cistern, displacing the pituitary stalk to the right, which shows normal signal and thickness and does not reach the optic chiasm.

Inferiorly, it reaches the clivus and protrudes into the posterior wall of the sphenoid sinus. Laterally, it extends to the cavernous sinuses, more extensively on the left side, with patent internal carotid arteries. On the left side, it protrudes into the middle fossa, making it difficult to rule out the integrity of the sphenoid bone with this technique, and exerts a mass effect on the anterior part of the left temporal lobe, which shows no signal alterations or abnormal enhancements. These findings correspond to a pituitary macroadenoma. Ectasia of the supratentorial ventricular system with prominent sulci and cisterns, predominantly temporal, with grade 4 anterior temporal atrophy (abnormal for the patient’s age). Scattered isolated T2 hyperintense foci in the white matter of both cerebral hemispheres due to mild ischemic leukoencephalopathy from small vessel disease (Fazekas 1). Prominent Virchow-Robin spaces.