Interactive Transcript
0:00
Dr. Laser, this is a 61-year-old male,
0:02
has an interesting history prior
0:04
cerebellar meningioma, prostate cancer
0:07
with radical prostatectomy previously performed,
0:11
and I will say that prostate cancer is
0:13
one of those cancers that is meningioma like.
0:16
It's a pretty dense cancer.
0:18
You kinda get that feel
0:20
because you know that it's bony metastases
0:22
are very packed and very sclerotic,
0:25
and so there's some translation of that into the brain.
0:28
So when you get brain mets, in my experience,
0:31
yes, they can be calvarial and be
0:33
sclerotic and low in signal,
0:35
but I've seen them on multiple occasions
0:36
along with colon,
0:38
be dural-based
0:39
and be very packed with very little cytoplasm
0:42
so that they're kind of gray and they can mimic meningioma.
0:46
Now in this case, we have a mass
0:48
that's intimate with the sella in the suprasellar region,
0:51
involves the anterior clinoid off to the side,
0:54
involves the planum sphenoidale and limbus sphenoidalis,
0:58
and the question is,
0:59
is this juicy pituitary gland giving rise,
1:01
making a baby out of this lesion?
1:04
Giving birth to it and extruding it up out of the birth canal?
1:07
Or is it a separate, you know,
1:09
is it a separate lesion coming on down?
1:12
I think the coronal projections are kind of tough, actually.
1:15
When you look at it on the T2 coronal,
1:19
it looks like a perfect mushroom, right?
1:21
There's the pituitary gland
1:23
and then you have a sort of snowman or mushroom effect,
1:26
which is often described with pituitary macroadenoma.
1:28
Look at the contrast-enhanced MRI.
1:30
Very nice,
1:31
almost perfectly midline mushroom.
1:33
Your first instinct is to think, okay,
1:36
it's pretty much...
1:37
it's pretty enhancing,
1:38
it's pretty intense, it's very smooth
1:40
and it has that snowman-type effect.
1:43
So your initial reaction,
1:44
even with the vascular displacement
1:46
and the carotid terminus widening side to side is,
1:49
okay, pituitary adenoma.
1:52
But you'd be wrong,
1:53
and the reason you'd be wrong is
1:56
it's got this very flat dural
1:58
growth pattern,
1:59
which is typical of these skull-base
2:01
anterior cranial fossa,
2:03
sphenoid ridge meningiomas.
2:05
Let's pull down the axial T1.
2:07
What does that conjure up in your mind?
2:09
What diagnosis would you think of here?
2:11
So that single image,
2:14
all else being ignored,
2:15
would raise the possibility of a craniopharyngioma.
2:17
It looks like it's arising from the pituitary gland.
2:19
It's heterogeneous, it's got patchy enhancement,
2:21
soft tissue enhancement on each side of it,
2:23
so that'd be the first thought
2:24
looking at this single image.
2:26
Sure, and I think that's a real fair assessment.
2:29
And then when you get to the other planes
2:31
and the enhancement.
2:32
Very atypical for craniopharyngioma,
2:35
which is kind of like popcorn.
2:36
It's got a cholesterol,
2:38
calcium, sometimes blood,
2:40
some different epithelial elements,
2:42
so it's a mishmash of tissues inside.
2:46
It's kind of a schizophrenic
2:48
lesion in terms of its behavior.
2:50
And the fact that this thing is just flat out smooth,
2:54
goes heavily against that diagnosis.
2:56
Also, the growth pattern virtually excludes it.
2:59
There is a biphasic distribution in kids and adults,
3:02
so the age doesn't necessarily dissuade us from the diagnosis,
3:05
but everything else does.
3:07
So, even though the first thought for that cut
3:10
would be craniopharyngioma,
3:11
I think we could take that out of the equation.
3:14
Another thing I found is that
3:15
because meningiomas are so firm
3:17
they tend to do a lot more pushing,
3:19
so they'll press the carotid termini
3:22
a little more readily side to side
3:24
than the softer pituitary adenoma would do.
3:28
So, this is a meningioma.
3:32
It's a somewhat en plaque meningioma.
3:35
The original locus of origin is either the anterior
3:38
clinoid or the planum region,
3:41
and I think those are the teaching points.
3:43
Anything else you want to add?
3:44
I think the most important thing for this case is to
3:47
always look at your sagittal imaging
3:49
because that's going to really help you define
3:51
the lesion and to see the fat planes
3:52
and to see the characteristic of the lesion.
3:55
Great.
3:55
And yeah, you do see a little plane
3:57
between it
3:58
and the pituitary gland, if you look really hard.
4:00
One more blow-up image for you.
4:01
And then, Pomeranz and Laser out for this case.
4:04
There's the plane.
4:06
We're out. Thank you.
© 2024 MRI Online. All Rights Reserved.