GRADUAL SPONTANEOUS REGRESSION OF A LARGE PITUITARY MASS - SHOULD WE TRUST THE TIME TO HEAL SOME WOUNDS?

Spontaneous intracranial hypotension (SIH) is defined by reduced CSF pressure without an identifiable cause, hallmarked by acute onset of severe postural headache. Overlapping clinical presentation, MRI appearance, laboratory findings and prevalent risk population, may lead to diagnostic challenges in distinguishing SIH from the more common pituitary adenoma apoplexy (PAA). Cardinal MRI characteristics of SIH may be overlooked if sellar region examination is not coupled with a comprehensive cranial MRI examination. Pituitary enlargement in SIH was described with increased prevalence, but mostly as an incidental observation in neuroradiological series, without detailed functional pituitary assessment or follow-up.

A young female with SIH presented with an intra-suprasellar mass lesion, imitating PAA. Mildly affected pituitary function, absence of visual impairments, and favourable clinical course influenced the decision against urgent pituitary surgery. Subsequent MRI confirmed spontaneous regression in pituitary size in first 5 months, along with clinical, hormonal and perimetric stability. Her initial mild central hypocortisolism resolved spontaneously, while baseline and follow-up dynamic pituitary assessment revealed no other abnormalities. Subsequent 9 years of endocrinological and neuroradiological follow-up confirmed gradual spontaneous pituitary lesion reduction. Awareness is raised that SIH may constitute a diagnostic pitfall due to clinical, neuroradiologic and laboratory overlapping with PA apoplexy, potentially leading to unnecessary surgery.