Can a sellar cystic lesion cause seizures?

Sellar Cystic Lesions and Seizures: Clinical Correlation and Management

Yes, sellar cystic lesions can cause seizures, particularly when they extend beyond the sellar region or cause secondary effects such as inflammation, edema, or compression of adjacent brain tissue.

Pathophysiological Mechanisms

Sellar cystic lesions may trigger seizures through several mechanisms:

• Direct extension into adjacent brain parenchyma
• Mass effect causing compression of temporal or frontal lobes
• Perilesional edema and inflammation
• Disruption of hypothalamic-pituitary axis leading to hormonal imbalances
• Hydrocephalus or increased intracranial pressure

Types of Sellar Cystic Lesions Associated with Seizures

• Neurocysticercosis (NCC) involving the sellar region
• Rathke's cleft cysts with suprasellar extension
• Pituitary abscesses with surrounding inflammation
• Craniopharyngiomas with cystic components
• Other non-neoplastic cystic lesions of the sellar region

Clinical Presentation

Patients with sellar cystic lesions may present with:

• Seizures (focal or with secondary generalization)
• Headaches (often the most common symptom) 1
• Visual disturbances (visual field defects, diminished acuity) 2
• Endocrine abnormalities (hypopituitarism, hyperprolactinemia) 2
• Altered consciousness (in cases with significant mass effect)

Diagnostic Approach

1. Neuroimaging:

   • MRI with 3D volumetric sequencing is the gold standard 3
   • CT scan may identify calcifications (helpful in neurocysticercosis)

2. Endocrine evaluation:

   • Assess for pituitary hormone deficiencies
   • Rule out hyperprolactinemia due to stalk compression

3. Ophthalmological assessment:

   • Visual field testing
   • Visual acuity measurement

Management Algorithm

For Sellar Cystic Lesions with Seizures:

1. Initial Management:

   • Administer antiepileptic drugs for seizure control 3
   • Choose antiepileptic drugs based on side effect profile, drug interactions, and patient characteristics 3
   • Control elevated intracranial pressure if present (corticosteroids, surgical intervention if needed) 3

2. Specific Management Based on Lesion Type:

   a) If Neurocysticercosis is confirmed:

   • For viable parenchymal cysts (1-2 cysts): Albendazole monotherapy (15 mg/kg/day divided into 2 daily doses) for 10-14 days 3
   • For multiple cysts (>2): Combination of albendazole (15 mg/kg/day) and praziquantel (50 mg/kg/day) for 10-14 days 3
   • Always administer corticosteroids before antiparasitic therapy 3
   • Never use antiparasitic drugs in patients with untreated hydrocephalus or diffuse cerebral edema 3, 4

   b) If Non-infectious cystic lesion:

   • Surgical approach is often required 1
   • Transsphenoidal approach for lesions confined to sella 5
   • Transcranial approach for large lesions with significant suprasellar extension 5

3. Follow-up:

   • MRI every 6 months until resolution of cystic lesions 3
   • Monitor seizure control and adjust antiepileptic medication as needed
   • Assess for improvement or deterioration in endocrine function

Antiepileptic Drug Management

• Continue antiepileptic drugs while the lesion is present 3
• Consider tapering off antiepileptic drugs after 6 months seizure-free AND resolution of the lesion on imaging 3
• Continue antiepileptic drugs if risk factors for recurrent seizures exist (residual cystic lesions, calcifications, history of multiple seizures) 3

Surgical Considerations

• Prompt surgical intervention may be necessary for:
  • Progressive visual loss
  • Intractable seizures
  • Significant mass effect
  • Diagnostic uncertainty requiring tissue diagnosis
• Surgical approach depends on lesion location, size, and extension 5, 2

Prognosis

• Visual deficits may persist despite treatment 2
• Endocrine abnormalities often remain after surgical intervention 2
• Seizure control is generally good with appropriate treatment
• Recurrence of cystic lesions is possible, requiring long-term monitoring 1

Important Caveats

• Right-sided lesions, particularly those involving the frontal cortex, have a higher association with secondary generalization of seizures 6
• Intrasellar cysticercosis is rare and often underrecognized but should be considered in endemic regions 2
• Cysticidal drug therapy may not be effective for isolated intrasellar cysticercosis 2
• Differential diagnosis of sellar cystic lesions is broad and includes both neoplastic and non-neoplastic etiologies 5, 1