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.