.JOUR:"AL OF THE AMERICA:" (;ERIATRICS SOCIETY Copyright © 197:i hv the American Geriatric» Sorietv
Vol. XXIII. 1\0. 12 Printed in U.S.A.
Craniopharyngioma in the Elderly Patient: Case Report A. A. SCHONDER, MD*
Reno, Nevada
ABSTRACT: A case is presented of craniopharyngioma in a 78-year-old woman. The symptoms and signs, except for those in the visual fields, were nonspecific. A review of the literature shows that this case history is representative of craniopharyngioma in the older adult. The findings in this elderly patient are contrasted with the signs and symptoms of craniopharyngioma in children.
peared normal. Pigment dispersion was evident in both maculae. The tangent screen examination revealed a defect in both upper temporal quadrants (Fig. 1A). The blepharochalasis was considered as possibly contributing to the visual field defects. Six weeks later (January 1972) the patient was feeling worse. She was depressed and anxious. Visual acuity with correction had fallen to 20/50 in the right eye and to 20/60 in the left. Complete bitemporal hemianopsia had developed (Fig. 18). X-ray examination of the skull and orbits revealed arteriosclerotic plaques in both internal carotid arteries. An electroencephalogram and brain scan were normal. A bruit was heard over each common carotid artery. No other abnormalities were found. In March 1972, three months after the onset of her complaints, visual acuity had decreased to 20/70 in the right eye and to 20/100 in the left. The optic discs appeared healthy. There was corresponding deterioration of the visual fields (Fig. l C). A carotid arteriogram confirmed arteriosclerotic changes in the internal carotid arteries. A pneumoencephalogram (Fig. 2) showed a deformity of the third ventricle, suggesting that a mass in the suprasellar space was distorting the region of the optic chiasm. In April 1972, a craniotomy was performed. A mass containing yellowish fluid was found beneath the optic chiasm. Biopsy established the diagnosis of craniopharyngioma (Fig. 3). The cystic lesion was decompressed, but complete excision could not be accomplished. One month after the operation, the patient was feeling well. She was no longer depressed or
Craniopharyngioma, a tumor found most commonly during childhood, may occur at any age. The identification and successful treatment of a craniopharyngioma in an elderly woman prompted the presentation of the following report. CASE REPORT The patient, a 78-year-old housewife, was first examined in 1958. Visual acuity with correction was 20/25 in the right eye and 20 in the left Mild macular degenerative changes were present in both eyes. Tangent screen examination revealed no visual field defects. No other abnormalities were observed. During the next 12 years, routine evaluations including tangent screen examinations performed yearly. revealed no significant changes beyond a slight decrease in corrected visual acuity to 20/40 in each eye. This was attributed to slight progression of the degenerative macular changes. In December 1971, the patient stated that "something is going wrong." She appeared agitated and her gait was unsteady. Visual acuity with correction was 20/40 in each eye. Pronounced blepharochalasis of both upper eyelids was noted. Both corneas showed arcus senilis. The right pupil was 1 mm larger than the left, but both were round and regular, and reacted promptly to light; the accommodation reflex was normal. Intraocular tension was 16 mm in each eye. The optic discs were flat and pink. The retinal vessels apClinical Assistant Professor of Surgery. University of Nevada Medical School. Reno. Address: A. A. Schonder, MD, 17.'; West Sixth Street. Reno, NV 89503.
545
Vol. XX/IJ
A. A. SCHONDER
~ "1Jo
J!l, . . ..
.. ,
t-' ",'
CJ
1'"
R.20/S0 + L.20/40
December 1971
anxious. Her gait had returned to normal. Visual acuity had improved to 20/40 in hoth eyes. No visual field defects were apparent. The appearance of the optic discs was unchanged. The right pupil remained 1 mm larger than the left. According to the findings at subsequent examinations. her condition has remained stahle. DISCUSSION
R.20/S0 L.20/60(mlssed leller on lell side 01 chart}
Craniopharyngioma accounts for 4 percent of all intracranial neoplasms and :30 percent of pitui-
January 1912
R.20110 L.20/200(20/60 right-hand I lIers) March 1912
Fig, I. Changes in visual fields and visual acuity in an aged patient with craniopharyngioma. (The tangent screen visual fields were determined with a 2-mm white test object at a distance of 1 meter from the patient.) A. December 1971. A defect was found in both upper temporal quadrants. B. January 1972. Complete bitemporal hemianopsia and decrease in visual acuity. C. March 1972. Further deterioration of the visual fields and visual acuity.
Fiu. 2. Pneumoencephalogram. showing deformity of the third ventricle.
Fig. 3. Microscopic section of the craniopharyngioma.
546
December 1975
CRANIOPHARYNGIOMA IN THE ELDERLY
tary tumors (1). It is the most common supratentorial tumor of children. Despite the greater incidence among the young, adults of any age may be affected. In a series of 108 cases reported by Love and Marshall (1), 9 patients were between the ages of 50 and 62. Hoff and Patterson (2) reviewed 51 cases; of these patients, 29 were between the ages of 22 and 67. The symptoms and signs of craniopharyngioma in the child differ from those in the adult. The presenting symptoms in children usually are related to the increased intracranial pressure which follows obstruction of the third ventricle, and may include headaches, nausea and vomiting. Papilledema is seen frequently, and separation of cranial suture lines may be present. Specific visual field changes often are absent (3). Even when present, they may be difficult to document because of the young age of the patient. The early clinical manifestations in the adult are often quite different from those in the child. There may be nonspecific changes in mood (i.e., anxiety and depression), mental confusion and loss of memory. Russell and Pennybacker (:3) reported that half of their series of 22 adults with craniopharyngioma had loss of memory. Eight of their patients had mental disturbances from 6 to 24 months before diagnosis, and 3 were admitted to mental hospitals before the true nature of their problem was identified. The key to correct diagnosis is the presence of bitemporal visual field defects. Hoff and Patterson (2) found such defects in 86 percent of their craniopharyngioma patients. Hypopituitarism may occur in patients of any age with craniopharyngioma, but usually the
signs are less obvious in adults because growth and sexual maturation are complete (3, 4). X-ray films of the skull are of more diagnostic help in children than in adults. Suprasellar calcification occurred in 81 percent of children with craniopharyngioma in the Hoff and Patterson series (2) whereas it was noted in less than half of their adult patients. In only one-quarter of adult patients with craniopharyngioma can an enlarged sella turcica be demonstrated (1). COMMENT Important points demonstrated by this case are: 1) the difference in the presenting symptoms and signs of craniopharyngioma in children as compared with adults, and 2) the necessity for visual field examination in the adult patient who exhibits anxiety, depression, memory loss or other nonspecific changes in mental status.
Acknowledgment We thank Jerry Donin, MD for assistance the data for publication.
In
preparing
REFERENCES 1. Love .JG and Marshall TM: Craniopharyngiomas. Surg Gynec Obst 90: 591. 1950. 2. Hoff JT and Patterson RH Jr: Craniopharyngiomas in children and adults.•J Neurosurg 36: 299, 1972. 3. Russell RWR and Pennybacker JB: Craniopharyngioma in tbe elderly, J Neurol Neurosurg Psychiat 24:1. 1961. 4. Bartlett .JR: Craniopharyngiomas. An analysis of some aspects of symptomatology, radiology and histology, Brain 94:725, 1971.
547
Vol. XXIII. 1\0. 12 Printed in U.S.A.
Craniopharyngioma in the Elderly Patient: Case Report A. A. SCHONDER, MD*
Reno, Nevada
ABSTRACT: A case is presented of craniopharyngioma in a 78-year-old woman. The symptoms and signs, except for those in the visual fields, were nonspecific. A review of the literature shows that this case history is representative of craniopharyngioma in the older adult. The findings in this elderly patient are contrasted with the signs and symptoms of craniopharyngioma in children.
peared normal. Pigment dispersion was evident in both maculae. The tangent screen examination revealed a defect in both upper temporal quadrants (Fig. 1A). The blepharochalasis was considered as possibly contributing to the visual field defects. Six weeks later (January 1972) the patient was feeling worse. She was depressed and anxious. Visual acuity with correction had fallen to 20/50 in the right eye and to 20/60 in the left. Complete bitemporal hemianopsia had developed (Fig. 18). X-ray examination of the skull and orbits revealed arteriosclerotic plaques in both internal carotid arteries. An electroencephalogram and brain scan were normal. A bruit was heard over each common carotid artery. No other abnormalities were found. In March 1972, three months after the onset of her complaints, visual acuity had decreased to 20/70 in the right eye and to 20/100 in the left. The optic discs appeared healthy. There was corresponding deterioration of the visual fields (Fig. l C). A carotid arteriogram confirmed arteriosclerotic changes in the internal carotid arteries. A pneumoencephalogram (Fig. 2) showed a deformity of the third ventricle, suggesting that a mass in the suprasellar space was distorting the region of the optic chiasm. In April 1972, a craniotomy was performed. A mass containing yellowish fluid was found beneath the optic chiasm. Biopsy established the diagnosis of craniopharyngioma (Fig. 3). The cystic lesion was decompressed, but complete excision could not be accomplished. One month after the operation, the patient was feeling well. She was no longer depressed or
Craniopharyngioma, a tumor found most commonly during childhood, may occur at any age. The identification and successful treatment of a craniopharyngioma in an elderly woman prompted the presentation of the following report. CASE REPORT The patient, a 78-year-old housewife, was first examined in 1958. Visual acuity with correction was 20/25 in the right eye and 20 in the left Mild macular degenerative changes were present in both eyes. Tangent screen examination revealed no visual field defects. No other abnormalities were observed. During the next 12 years, routine evaluations including tangent screen examinations performed yearly. revealed no significant changes beyond a slight decrease in corrected visual acuity to 20/40 in each eye. This was attributed to slight progression of the degenerative macular changes. In December 1971, the patient stated that "something is going wrong." She appeared agitated and her gait was unsteady. Visual acuity with correction was 20/40 in each eye. Pronounced blepharochalasis of both upper eyelids was noted. Both corneas showed arcus senilis. The right pupil was 1 mm larger than the left, but both were round and regular, and reacted promptly to light; the accommodation reflex was normal. Intraocular tension was 16 mm in each eye. The optic discs were flat and pink. The retinal vessels apClinical Assistant Professor of Surgery. University of Nevada Medical School. Reno. Address: A. A. Schonder, MD, 17.'; West Sixth Street. Reno, NV 89503.
545
Vol. XX/IJ
A. A. SCHONDER
~ "1Jo
J!l, . . ..
.. ,
t-' ",'
CJ
1'"
R.20/S0 + L.20/40
December 1971
anxious. Her gait had returned to normal. Visual acuity had improved to 20/40 in hoth eyes. No visual field defects were apparent. The appearance of the optic discs was unchanged. The right pupil remained 1 mm larger than the left. According to the findings at subsequent examinations. her condition has remained stahle. DISCUSSION
R.20/S0 L.20/60(mlssed leller on lell side 01 chart}
Craniopharyngioma accounts for 4 percent of all intracranial neoplasms and :30 percent of pitui-
January 1912
R.20110 L.20/200(20/60 right-hand I lIers) March 1912
Fig, I. Changes in visual fields and visual acuity in an aged patient with craniopharyngioma. (The tangent screen visual fields were determined with a 2-mm white test object at a distance of 1 meter from the patient.) A. December 1971. A defect was found in both upper temporal quadrants. B. January 1972. Complete bitemporal hemianopsia and decrease in visual acuity. C. March 1972. Further deterioration of the visual fields and visual acuity.
Fiu. 2. Pneumoencephalogram. showing deformity of the third ventricle.
Fig. 3. Microscopic section of the craniopharyngioma.
546
December 1975
CRANIOPHARYNGIOMA IN THE ELDERLY
tary tumors (1). It is the most common supratentorial tumor of children. Despite the greater incidence among the young, adults of any age may be affected. In a series of 108 cases reported by Love and Marshall (1), 9 patients were between the ages of 50 and 62. Hoff and Patterson (2) reviewed 51 cases; of these patients, 29 were between the ages of 22 and 67. The symptoms and signs of craniopharyngioma in the child differ from those in the adult. The presenting symptoms in children usually are related to the increased intracranial pressure which follows obstruction of the third ventricle, and may include headaches, nausea and vomiting. Papilledema is seen frequently, and separation of cranial suture lines may be present. Specific visual field changes often are absent (3). Even when present, they may be difficult to document because of the young age of the patient. The early clinical manifestations in the adult are often quite different from those in the child. There may be nonspecific changes in mood (i.e., anxiety and depression), mental confusion and loss of memory. Russell and Pennybacker (:3) reported that half of their series of 22 adults with craniopharyngioma had loss of memory. Eight of their patients had mental disturbances from 6 to 24 months before diagnosis, and 3 were admitted to mental hospitals before the true nature of their problem was identified. The key to correct diagnosis is the presence of bitemporal visual field defects. Hoff and Patterson (2) found such defects in 86 percent of their craniopharyngioma patients. Hypopituitarism may occur in patients of any age with craniopharyngioma, but usually the
signs are less obvious in adults because growth and sexual maturation are complete (3, 4). X-ray films of the skull are of more diagnostic help in children than in adults. Suprasellar calcification occurred in 81 percent of children with craniopharyngioma in the Hoff and Patterson series (2) whereas it was noted in less than half of their adult patients. In only one-quarter of adult patients with craniopharyngioma can an enlarged sella turcica be demonstrated (1). COMMENT Important points demonstrated by this case are: 1) the difference in the presenting symptoms and signs of craniopharyngioma in children as compared with adults, and 2) the necessity for visual field examination in the adult patient who exhibits anxiety, depression, memory loss or other nonspecific changes in mental status.
Acknowledgment We thank Jerry Donin, MD for assistance the data for publication.
In
preparing
REFERENCES 1. Love .JG and Marshall TM: Craniopharyngiomas. Surg Gynec Obst 90: 591. 1950. 2. Hoff JT and Patterson RH Jr: Craniopharyngiomas in children and adults.•J Neurosurg 36: 299, 1972. 3. Russell RWR and Pennybacker JB: Craniopharyngioma in tbe elderly, J Neurol Neurosurg Psychiat 24:1. 1961. 4. Bartlett .JR: Craniopharyngiomas. An analysis of some aspects of symptomatology, radiology and histology, Brain 94:725, 1971.
547
