A 55-year-old truck driver comes to the office due to impaired vision over the past 6 months. He has had increasing difficulty when looking sideways and now has to completely turn his neck to look to the side. He also has intermittent headaches that worsen in the morning. The patient recently developed a decreased libido, which he attributes to his long work hours and night shifts. He has no fever, weakness or numbness, or bladder/bowel problems. His BMI is 32 kg/m². Examination shows decreased vision in the temporal fields on both sides. Neurological examination shows 5/5 muscle strength, normal sensation, normal gait and coordination, and 2+ deep tendon reflexes. Which of the following is the most likely diagnosis?

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11ec25c8_d5c4_958a_bc81_679dedcef226_MD0003_00 This patient's presentation is consistent with a sellar mass, causing visual defects (eg, bitemporal hemianopsia), headache, and symptoms of pituitary hormonal deficiencies (eg, decreased libido due to hypogonadism). They can also be found incidentally on brain imaging. Sellar masses can be either malignant or benign (eg, pituitary adenoma, craniopharyngioma, meningioma). Craniopharyngiomas are benign tumors arising from Rathke's pouch and most commonly occur in children. However, nearly 50% of craniopharyngiomas occur in individuals age >20, especially between ages 55-65. These tumors usually grow gradually over a period of years and cause slowly progressive symptoms. They can compress the optic chiasm leading to bitemporal blindness. The diagnosis is confirmed with an MRI or CT scan, and treatment includes surgery and/or radiotherapy. bitemporal blindness (Choices A) Cerebellopontine angle (CPA) tumors (eg, acoustic neuromas, meningiomas) cause headache, hearing loss, vertigo, tinnitus, or balance problems. CPA tumors do not usually cause visual disturbances as they are below the optic pathways. acoustic neuromas (Choice C) Glioblastoma multiforme typically presents with progressively worsening headache, visual abnormalities, focal motor weakness, and cognitive deficits. (Choice D) Migraine headaches can cause transient neurological findings, including visual disturbances. However, they are not usually associated with persistent visual field defects or endocrine symptoms. (Choice E) Sarcoidosis can infiltrate the pituitary to cause bitemporal hemianopsia. However, sarcoidosis usually presents initially with pulmonary symptoms such as cough, dyspnea, wheezing, or chest pain. (Choice F) Open-angle glaucoma causes gradual loss of peripheral vision in both eyes, leading to tunnel vision, rather than bitemporal hemianopsia. It also would not cause headache or endocrine symptoms. (Choice G) Optic neuritis is an inflammatory demyelinating disease usually associated with multiple sclerosis. Patients typically develop acute to subacute painful vision loss with abnormal pupillary response to light in the affected eye. (Choice H) Pseudotumor cerebri (idiopathic intracranial hypertension) is most common in obese women age <45 and presents with headache, transient visual symptoms, and pulsatile tinnitus. Examination shows papilledema, visual field loss, and sixth nerve palsy. (Choice I) Temporal lobe stroke can affect the inferior optic radiations in the loop of Meyer and cause homonymous superior quadrantanopsia. By contrast, the presence of bitemporal visual deficits, as in this patient, suggests optic chiasm involvement. In addition, a stroke would not cause progressively worsening visual symptoms as seen in this patient. homonymous superior quadrantanopsia optic chiasm Educational objective: Craniopharyngiomas are benign suprasellar tumors that present with visual defects, headache, and symptoms of pituitary hormonal deficiencies. References: Craniopharyngioma. (http://www.ncbi.nlm.nih.gov/pubmed/21819881) Craniopharyngioma: a pathologic, clinical, and surgical review. (http://www.ncbi.nlm.nih.gov/pubmed/21584897)

A 55-Year-Old Truck Driver Comes to the Office Due to Impaired