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16b - Answer: 40-year-old female presents with history of left lower quadrant visual loss

Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
Includes DICOM files

HISTORY: 

This 40-year-old female presents with history of left lower quadrant visual loss, migraines, and pituitary adenoma.

(QUIZ ANSWER) IT IS POSSIBLE THAT THE VISUAL DISTURBANCE DESCRIBED IS IN ASSOCIATION WITH EMPTY SELLA AND OPTIC CHIASMAL HERNIATION: 

True.

Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.

FINDINGS:

Empty sella with pituitary stalk deviated to the right. No suprasellar masses. No hypointensity within the sella on precontrast images. No cavernous sinus enlargement. No chiasmal compression. No enlargement of the extraocular muscles. Cerebral hemispheres and deep nuclei are without hemorrhage, mass or edema. No masses in the masticator, parapharyngeal or pharyngeal mucosal spaces. Nigral and pallidal iron stores are maintained. Orbital apices, optic chiasm, optic tracts, lateral geniculate and visual cortices are unremarkable. 

No confluent otomastoid airspace disease. 

No internal auditory canal masses. 

Venous sinuses are patent. 

No extraaxial collections or hemorrhage. No obstructive hydrocephalus. No vermian or hemispheric cerebellar atrophy. No optic nerve sheath dilatation or globe flattening. No Chiari malformation. 

On coronal T2 series, the optic chiasm is slightly downwardly drawn with the optic nerves exiting anterosuperiorly. 

CONCLUSION: 

1. Empty sella with pituitary stalk that is deviated to the right. No suprasellar masses or chiasmal compression. Abnormal configuration of the optic chiasm with the optic nerves exiting superiorly. In the setting of empty sella finding could represent mild form of optic apparatus herniation which has been associated with empty sella. Visual disturbance has been described in associated with empty sella and optic chiasmal herniation. No herniation of the hypothalamic recess. Finding could be relevant in the provided setting of visual disturbance. 

2. No macroadenoma. No discrete microadenoma. 

3. No obstructive hydrocephalus. 

4. No evidence of acute supra- or infratentorial ischemia or demyelination. 

ADDENDUM: 

Examination was re-reviewed in neuro conference. Empty sella has been associated indirectly with intracranial hypertension. In the setting of headaches and visual disturbance, eye examination to exclude papilledema is recommended. No optic nerve sheath dilatation or globe flattening.

LESSON 2, TOPIC 48

Case Challenge: Sella MRI Cases

Case Challenge

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Content reviewed: July 15, 2021

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