Pituitary Abscess: A Challenging Preoperative Diagnosis—A Multicenter Study

Abstract

Background and Objectives: Pituitary abscess (PA) is a rare occurrence, representing less than 1% of pituitary lesions, and is defined by the presence of an infected purulent collection within the sella turcica. Pas can be classified as either primary, when the underlying pituitary is normal prior to infection, or secondary, when there is associated a pre-existing sellar pathology (i.e., pituitary adenoma, Rathke’s cleft cysts, or craniopharyngioma), with or without a recent history of surgery. Preoperative diagnosis, owing to both non-specific symptoms and imaging features, remains challenging. Treatment options include endonasal trans-sphenoidal pus evacuation, as well as culture and tailored antibiotic therapy. Methods: A retrospective multicenter study, conducted on a prospectively built database over a 20-year period, identified a large series of 84 patients harboring primary sellar abscess. The study aimed to identify crucial clinical and imaging features in order to accelerate appropriate management. Results: The most common clinical presentation was a symptom triad consisting of various degrees of asthenia (75%), visual impairment (71%), and headache (50%). Diagnosis was achieved in 95% of cases peri- or postoperatively. Functional recovery was good for visual disturbances and headache. Pituitary function recovery remained very poor (23%), whereas the preoperative diagnosis represented a protective factor. Conclusions: In light of the high prevalence of pituitary dysfunction following the management of PAs, early diagnosis and treatment might represent a crucial issue. Currently, there are no standard investigations to establish a conclusive preoperative diagnosis; however, new, emerging imaging methods, in particular nuclear imaging modalities, represent a very promising tool, whose potential warrants further investigations.

Endoscopic endonasal transsphenoidal surgery for unusual sellar lesions: eight cases and review of the literature

“…PA are rare, comprising less than 1% of pituitary lesions, characterized by an infected purulent collection within the sellar turcica ( 35 ). In our case series, two cases of PA were inaccurately diagnosed as Rathke’s cyst through imaging alone.…”

Characteristics of inflammatory and infectious diseases of the pituitary gland in patients undergoing transsphenoidal surgery

“…Although first reported over 150 years ago, pituitary abscess remains an elusive pathology. Most cases are reported in small retrospective series and single case reports [ 7 , 27 , 28 ]. Similar to our series (0,76%), the incidence has been approximated between 0.7 and 1% of all TSS.…”

“…Similar to our series (0,76%), the incidence has been approximated between 0.7 and 1% of all TSS. In total, approximately 500 cases of pituitary abscess have been reported in the literature [ 7 , 27 , 28 ].…”

Case report: Diagnosis and treatment of delayed epidural pyogenic abscess after brain tumor operation: a report of 5 cases and review of the literature

“…However, the specificity and sensitivity of DWI for diagnosing intracranial infection are somewhat affected by blood composition after surgery ( 10 ). The absence of diffusion restriction on MRI DWI does not completely rule out the diagnosis of abscess, because the effect of paramagnetic susceptibility at the base of the skull near the craniofacial sinuses may affect signal scattering and create artifacts ( 13 ). Some scholars have found that Nuclear medicine is considered as an alternative to traditional MRI when evaluating the infection near the skull base, especially the application of new contrast enhancement agents in neuroradiology, and Nuclear medicine can improve the accuracy of postoperative infection detection ( 13 , 14 ).…”

“…The absence of diffusion restriction on MRI DWI does not completely rule out the diagnosis of abscess, because the effect of paramagnetic susceptibility at the base of the skull near the craniofacial sinuses may affect signal scattering and create artifacts ( 13 ). Some scholars have found that Nuclear medicine is considered as an alternative to traditional MRI when evaluating the infection near the skull base, especially the application of new contrast enhancement agents in neuroradiology, and Nuclear medicine can improve the accuracy of postoperative infection detection ( 13 , 14 ). Earlier literature reported that aerobic Gram-negative bacteria accounted for less than 10% of isolates, while in Hlavin et al's report, the aerobic Gram-negative bacteria were cultured in 52% of patients ( 7 ).…”