Two Perplexing Cases of Craniopharyngioma

Case 1: A 19 yo man presented with sinus pressure, headaches, and neck stiffness not relieved by a course of antibiotics. He subsequently noticed bilateral loss of peripheral vision and binocular horizontal diplopia. Exam revealed a VA of 20/30 OD and 20/40 OS without relative afferent pupillary defect and with alternating esophoria on alternate cover test. Fundus exam showed bilateral disc edema. CT head revealed a suprasellar mass with calcified, solid enhancing, and cystic components. MRI head showed a suprasellar large cystic mass with peripheral enhancement resulting in obstructive hydrocephalus with transependymal CSF flow. He received intravenous dexamethasone and subsequent right frontal intracranial intraventricular endoscopy with cyst wall fenestration and aspiration. Pathology confirmed craniopharyngioma with acellular calcific or keratinous material. Case 2: A 9 yo girl presented with one month of severe vision loss, longstanding frontal HA and dizziness. Exam revealed a VA of 20/200 OU with no relative afferent pupillary defect and grade V optic disc edema OU on fundus exam. MRI revealed a large heterogeneously enhancing suprasellar mass with T1 hyperintense proteinaceous components on pre-contrast images with obstructive hydrocephalus. She received intravenous dexamethasone and an external ventricular drain followed by decompressive resection of the mass. Pathology showed an adamantinomatous craniopharyngioma. After discharge, she developed a large right subdural fluid collection with a midline shift and required subdural peritoneal shunt. Unfortunately, the patient had LP vision OU at follow up.