Bilateral visual failure with optic tract involvement in sellar-suprasellar lymphoma: illustrative case

Visual dysfunction related to sellar lesions is usually attributed to chronic compression of the optic chiasm, typically following an insidious, progressive course. Abrupt or disproportionately rapid visual failure should therefore prompt careful evaluation for alternative or additional mechanisms.

A 69-year-old woman experienced progressive visual deterioration over 3 months, followed by near-complete bilateral visual loss within 1 week. Visual field testing showed severe bilateral generalized depression. Dedicated sellar enhanced MRI revealed a large sellar-suprasellar mass compressing the optic chiasm. In addition to mass effect, contrast-enhanced images demonstrated optic tract enhancement and avid leptomeningeal enhancement, raising concern for spread along the optic tracts and meningeal dissemination beyond the primary sellar-suprasellar region. Axial fluid-attenuated inversion recovery sequences further showed bilateral optic tract hyperintensity with signal abnormalities extending to the adjacent hypothalamic structures. The patient underwent endoscopic transsphenoidal tumor resection. Pathological examination confirmed aggressive B-cell lymphoma (CD20+, CD79a+, CD5+, Ki-67 index 90%).

This case emphasizes that, in sellar lesions presenting with rapidly progressive visual loss, radiological assessment should extend beyond the sellar mass and optic chiasm to include the optic tracts and adjacent postchiasmatic visual pathway. https://thejns.org/doi/10.3171/CASE26610.