Case report of transsphenoidal meningocele presenting as airway obstruction and panhypopituitarism: Radiological findings and the role of CSF flow analysis.

A 33-year-old male presented with "nasal obstruction," polyuria and polydipsia for a few years. His hormonal profile revealed panhypopituitarism, prompting pituitary imaging. Initial magnetic resonance imaging (MRI) findings in another institute diagnosed a craniopharyngioma with large cystic component. Subsequent follow-up MRI at our center revealed a large cystic sellar lesion that follows cerebrospinal fluid (CSF) intensity across all sequences. There was communication to the anterior recess of the third ventricle, and infrasellar extension via the sphenoid sinus into the nasopharynx, causing significant narrowing of the nasopharyngeal airway. There was no appreciable internal solid component, contrast enhancement or diffusion restriction. CSF flow analysis revealed bidirectional flow between the lesion and the anterior recess of the third ventricle, confirming direct communication between the lesion and CSF space. Overall imaging features were compatible with a transsphenoidal meningocele. Surgical repair was not performed as the chronic hormonal disturbances were deemed to be irreversible, with a high chance of recurrent post-operative CSF leak. Conservative management with long-term hormonal replacement therapy was initiated. This case illustrates atypical presentation of pituitary lesion resulting in airway obstruction and delayed diagnosis of panhypopituitarism in adulthood; as well as the underrecognized differential diagnoses of a cystic sellar mass.