“Zebras” in a sea of horses : A retrospective cohort analysis of non-adenomatous pituitary lesions managed at a tertiary care center

Background Non-adenomatous pituitary lesions are rare and often misdiagnosed as pituitary adenomas. Accurate diagnosis is crucial to avoid unnecessary surgery and to tailor treatment approaches appropriately Methods A retrospective cohort study was conducted at Nizam's Institute of Medical Sciences, Hyderabad, from 2019 to 2024, including 18 patients with histologically confirmed non-adenomatous pituitary lesions. Clinical features, hormonal profiles, radiological characteristics, interventions, and outcomes were analyzed. Results Of the 18 patients, 77.7% were female. Mean age was 42.1 years and mean follow-up was 19.17 months. Presenting symptoms included neurological deficits in 83.4% and endocrine disturbances in 88.8%. Histopathological classifications included inflammatory/granulomatous (55.5%), Rathke’s cleft cysts (22.2%), neurohypophyseal tumors (11.1%), and arachnoid cysts (11.1%). Biopsy was performed in 33.3%, transsphenoidal surgery in 61.1%, and craniotomy in 5.5%. Hormone replacement was needed in 77.7% post-intervention. Mortality was 11.1%, and recurrence was 5.5%. Conclusion Non-adenomatous pituitary lesions remain an elusive set of entities to neurosurgeons, radiologists and endocrinologists alike due to their varied presentations and subtle imaging findings that may be overlooked and mistook as the more common pituitary adenomas. An attention to demographic clues and knowledge of clinico-radiology of these lesions maybe helpful to identify these “zebras” from the usual herd of “horses” that are pituitary adenomas.