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Pituitary Macroadenoma

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0:00

Dr. Shupek.

0:01

We've got a 22-year-old young woman who has a mass,

0:07

a coronal T1-weighted image, non-contrast.

0:10

It's a large mass facing the ventricles,

0:13

a coronal T2 fast spine echo,

0:16

and a coronal contrast-enhanced MRI.

0:19

Our mass kind of has the shape of a snowman,

0:22

sort of a figure of eight.

0:24

You just trace it kind of looks like this.

0:27

And that figure-of-eight appearance is very typical

0:30

of a pituitary macroadenoma. Now, you might say,

0:33

well, what about a meningioma?

0:34

Well, meningiomas are kind of rock hard.

0:36

They're very firm,

0:37

so they tend not to have this wasted appearance

0:41

because they're not soft,

0:43

so they don't get constricted or restricted

0:45

by the diaphragma sellae.

0:48

As I scroll through these images for our viewing

0:51

audience of physicians and colleagues,

0:55

you see that the mass has a cystic component.

0:57

We're going to talk about that in the differential

0:59

diagnosis section. Don't see any calcification yet,

1:03

although we do see kind of a fluid-fluid level or

1:06

a blood-fluid level or a protein-fluid level.

1:09

And that's worth discussing because you could

1:12

have some blood inside the lesion,

1:14

which would be a potential concern for pituitary

1:17

apoplexy. And the lesion is very large.

1:20

It has both intrasellar components

1:22

and suprasellar components.

1:23

And one of the first things you need to do when

1:26

you look at a pituitary mass is decide,

1:29

did it arise from the top and come down or

1:31

did it arise from the sella and go up?

1:34

And then of course, you want to look medio-laterally.

1:37

Does it go off to the side?

1:39

Is it invading the cavernous sinus?

1:41

And we've given you many criteria

1:43

for that in other vignettes.

1:45

In keeping with kind of a formula for looking

1:48

at these when they're so big like this,

1:50

then you just go to the presellar area.

1:52

So you might go to, say,

1:53

a sagittal projection and say, okay,

1:56

does it go into the tuberculum sellae?

1:58

Does it go into the planum sphenoidale

2:00

or the limbus sphenoidale? Alice,

2:02

let me blow this up a little bit just

2:03

so we can see it a little better.

2:05

It's not our best sagittal image,

2:06

but I think you get the point.

2:08

There isn't much presellar or anterior extension.

2:12

And then you ask yourself, okay,

2:13

does it go in the middle fossa?

2:15

Does it encroach on the brainstem?

2:17

Does it go down? Is there an infrasellar component?

2:20

And there certainly is bowing of the floor of the

2:22

sella. It doesn't invade the clivus.

2:25

That's important, and it isn't retroclival.

2:28

So that's the basic approach to this lesion.

2:31

I'll scroll it again for you in the coronal

2:33

projection so you can see its posterior extension

2:36

and its anterior extension and its massive

2:40

encroachment on the optic apparatus.

2:42

You say to yourself, okay, where is it?

2:45

It's in here somewhere.

2:46

And the other thing you have to ask yourself is,

2:48

okay, what's it doing to the ventricles?

2:50

Is there obstructive hydrocephalus?

2:52

And that's going to be relevant surgically.

2:55

Yes, there is. Now,

2:56

we do have a T2-weighted image.

2:59

Let's take a look.

3:00

Look at the T2 appearance of this lesion in the

3:03

sagittal and in the coronal projection again,

3:06

and you see that fluid-fluid level once more,

3:10

and the dependent level is really dark.

3:12

So that pushes me towards it being blood as

3:15

opposed to protein. The darker it is,

3:17

the more likely it is to be intracellular

3:19

deoxyhemoglobin and met-hemoglobin and maybe

3:22

even some siderosis from blood.

3:24

So,

3:25

like blood as opposed to simple protein for this

3:29

blood-fluid level. So we've got a huge mass.

3:33

I think both of us would decide that it has

3:35

an intrasellar origin because, I mean,

3:37

where is the sella if it was from above?

3:40

Going down,

3:41

at least you'd see a little plane between

3:43

the mass and the sella turcica.

3:45

Now, the sella turcica can look like this,

3:49

and sometimes even the sella turcica will be J-shaped,

3:52

which is a variation that we haven't really

3:54

talked about in our variants section,

3:57

but it may look like this, and

3:59

that can be normal as well.

4:00

And some people will confuse that for partial empty

4:03

sella, but there isn't either one of those.

4:05

There's no plane of separation

4:07

between this and the sella.

4:08

So this almost has to be an intrasellar mass.

4:12

And you say to yourself, well,

4:13

what kind of mass could it be?

4:15

Well, with cystic components, you say to yourself,

4:17

could it be a craniopharyngioma?

4:18

But it's not starting supercellar,

4:20

it's starting in intrasellar. There's no calcification,

4:23

so craniopharyngioma is not a very good choice.

4:26

And this is going to be a macroadenoma.

4:30

And we're going to talk about what happened to this

4:31

22-year-old woman who had an elevated prolactin and

4:35

who also has cerebral palsy and some other findings

4:38

in the clinical section. So let's get to it.

4:40

Shall we? Sure.

Report

Description

Faculty

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Tags

Sella

Neuroradiology

Neoplastic

MRI

Head and Neck

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