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Dr. Shupek.

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

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a coronal T1-weighted image, non-contrast.

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It's a large mass facing the ventricles,

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a coronal T2 fast spine echo,

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and a coronal contrast-enhanced MRI.

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Our mass kind of has the shape of a snowman,

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sort of a figure of eight.

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You just trace it kind of looks like this.

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And that figure-of-eight appearance is very typical

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of a pituitary macroadenoma. Now, you might say,

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well, what about a meningioma?

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Well, meningiomas are kind of rock hard.

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They're very firm,

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so they tend not to have this wasted appearance

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because they're not soft,

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so they don't get constricted or restricted

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by the diaphragma sellae.

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As I scroll through these images for our viewing

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audience of physicians and colleagues,

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you see that the mass has a cystic component.

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We're going to talk about that in the differential

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diagnosis section. Don't see any calcification yet,

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

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

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And that's worth discussing because you could

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have some blood inside the lesion,

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which would be a potential concern for pituitary

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apoplexy. And the lesion is very large.

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It has both intrasellar components

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and suprasellar components.

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And one of the first things you need to do when

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you look at a pituitary mass is decide,

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did it arise from the top and come down or

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did it arise from the sella and go up?

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

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Does it go off to the side?

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Is it invading the cavernous sinus?

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And we've given you many criteria

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for that in other vignettes.

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In keeping with kind of a formula for looking

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at these when they're so big like this,

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then you just go to the presellar area.

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So you might go to, say,

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a sagittal projection and say, okay,

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does it go into the tuberculum sellae?

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Does it go into the planum sphenoidale

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or the limbus sphenoidale? Alice,

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let me blow this up a little bit just

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so we can see it a little better.

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It's not our best sagittal image,

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but I think you get the point.

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There isn't much presellar or anterior extension.

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And then you ask yourself, okay,

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does it go in the middle fossa?

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Does it encroach on the brainstem?

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Does it go down? Is there an infrasellar component?

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And there certainly is bowing of the floor of the

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sella. It doesn't invade the clivus.

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

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So that's the basic approach to this lesion.

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I'll scroll it again for you in the coronal

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projection so you can see its posterior extension

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and its anterior extension and its massive

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encroachment on the optic apparatus.

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You say to yourself, okay, where is it?

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It's in here somewhere.

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And the other thing you have to ask yourself is,

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okay, what's it doing to the ventricles?

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Is there obstructive hydrocephalus?

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And that's going to be relevant surgically.

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Yes, there is. Now,

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we do have a T2-weighted image.

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Let's take a look.

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Look at the T2 appearance of this lesion in the

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sagittal and in the coronal projection again,

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and you see that fluid-fluid level once more,

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and the dependent level is really dark.

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So that pushes me towards it being blood as

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opposed to protein. The darker it is,

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the more likely it is to be intracellular

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deoxyhemoglobin and met-hemoglobin and maybe

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even some siderosis from blood.

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So,

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like blood as opposed to simple protein for this

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

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I think both of us would decide that it has

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an intrasellar origin because, I mean,

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where is the sella if it was from above?

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Going down,

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at least you'd see a little plane between

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the mass and the sella turcica.

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Now, the sella turcica can look like this,

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

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which is a variation that we haven't really

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talked about in our variants section,

3:57

but it may look like this, and

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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

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between this and the sella.

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So this almost has to be an intrasellar mass.

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And you say to yourself, well,

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what kind of mass could it be?

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Well, with cystic components, you say to yourself,

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could it be a craniopharyngioma?

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But it's not starting supercellar,

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

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so craniopharyngioma is not a very good choice.

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And this is going to be a macroadenoma.

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

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

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who also has cerebral palsy and some other findings

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

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Shall we? Sure.