title: Cerebral arteriopathy with subcortical infarcts and leukoencephalopathy in acromegalic patient with severe headache.
abstract: A 68-year-old female patient was admitted in our clinic with severe frontal bilateral headache, dizziness, depression and cognitive decline in the context of a previously diagnosed acromegaly. She also had high blood pressure, dyslipidemia, secondary diabetes mellitus. Acromegaly was caused by a growth hormone (GH) secreting-pituitary macroadenoma, so a transsphenoidal surgery was performed. The postoperative magnetic resonance imaging (MRI) scan revealed a 20÷22÷25 mm pituitary mass remnant and medical therapy with somatostatin analogues (SSAs) was started. After nine months of treatment with SSAs, she continued having severe headache, the blood pressure was well controlled, but GH secretion was only partially controlled with insulin-like growth factor-1 (IGF-1) level still above the normal value. The MRI scan showed the same pituitary tumor remnant with supra- and parasellar right extension and also multiple fronto-temporo-parietal subcortical lesions that could suggest in the clinical context cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). According to a pregenetic screening tool, the Pescini Scale, the patient had a 19 points score, which is highly suggestive for CADASIL, an inherited cerebrovascular disease due to mutations of the Notch3 gene at the chromosome locus 19p13. In the absence of genetic testing, an alternate way to prove small vessels disease, the skin biopsy, was performed. Electron microscopy showed granular osmiophilic material (GOM) surrounding the vascular smooth muscle cells on that are pathognomonic for the disease. Our report underscores the importance of repeated investigations even in patients with apparently obvious explanations of their condition since they may have multiple diseases with the same presenting clinical signs.
authors.affiliation: Department of Endocrinology, "Carol Davila" University of Medicine and Pharmacy, "C. I. Parhon" National Institute of Endocrinology, Bucharest, Romania; badicrin@yahoo.co.uk.
authors.forename: LuminiŢa Nicoleta
authors.initials: LN
authors.lastname: Cima
authors.forename: Simona Vasilica
authors.initials: SV
authors.lastname: Fica
authors.forename: Alice Ioana
authors.initials: AI
authors.lastname: Albu
authors.forename: Ioana Maria
authors.initials: IM
authors.lastname: Lambrescu
authors.forename: Ioana SmărăndiŢa
authors.initials: IS
authors.lastname: Lăcău
authors.forename: Bogdan Ovidiu
authors.initials: BO
authors.lastname: Popescu
authors.forename: Mihaela
authors.initials: M
authors.lastname: Gherghiceanu
authors.forename: Corin Virgil
authors.initials: CV
authors.lastname: Badiu
authors.forename: Carmen Gabriela
authors.initials: CG
authors.lastname: Barbu
mesh_terms: D000172:Acromegaly; D000368:Aged; D046589:CADASIL / Q000209:etiology* / Q000473:pathology; D005260:Female; D006261:Headache / Q000209:etiology* / Q000473:pathology; D006801:Humans