0:00

Dr. Schupack,

0:01

we've got a 28-year-old male with visual loss,

0:04

probably a visual field cut,

0:06

a sagittal T1 with contrast,

0:09

some moderate but definite enhancement of our mass.

0:12

Here's the pre-contrast.

0:13

T one. Here's the post.

0:14

And here's the axial.

0:16

T two spin echo. So again,

0:18

in approaching a lesion of this size,

0:20

we want to know the gender,

0:21

we want to know the age which we have.

0:23

We want to see if the lesion is smooth and or solid,

0:26

which it is. Are there any cysts?

0:29

No. Is there calcium? No.

0:31

Is there blood? No. Is there fat?

0:33

Answer is no. Then we say to ourselves, okay,

0:37

is it intraaxial? For instance,

0:38

is it arising from the hypothalamus?

0:40

No. Is it arising extra axially?

0:43

Probably from the Pituitary gland, can't separate it out.

0:47

And then if it's intracellular,

0:49

what kind of other characteristics does it have?

0:52

And we've already alluded to those.

0:53

If it's supercellular, is it a general mass in an adult?

0:58

Or is it a pediatric patient?

1:00

If it's a pediatric patient,

1:01

then our differential diagnosis changes.

1:04

And then what's the status of the stalk in this case?

1:07

The stalk is compressed.

1:09

It clearly is not arising from the stalk.

1:11

It's not a primary stalk lesion like a

1:13

met or e g or sarcoid or pituocytoma.

1:17

And then we go back to the clinical question,

1:20

which is the patient has a visual field problem where's

1:23

the optic apparatus, it is markedly compressed.

1:26

So this lesion is going to be dealt with.

1:28

And then as I look at it and decide it's infrastellar

1:32

extension, I'm also thinking,

1:33

is there retrocellular extension? Yes, there is.

1:36

You can talk about that in a moment.

1:38

Is there anterior extension? Not much.

1:41

Is there infrastellar extension? There certainly is.

1:44

And is there paracellar extension?

1:46

There certainly is. To the left.

1:47

So I'll drive, and you can address some of those issues.

1:51

Okay, well, in the earlier vignette, dr.

1:56

Pomez gave a very detailed differential.

2:00

Of cellar supercellar masses.

2:01

And he loves to do stuff like that.

2:03

I do.

2:04

But I would say the first thing is if you look

2:09

at ones that really enlarge the cella,

2:11

that list gets a lot smaller.

2:13

True. Meaning something like sarcoid, epidermoid,

2:17

some of these things are just not going to do this.

2:20

So when you talk about things that are definitely

2:22

eroding and enlarging the cella,

2:25

you've already cut down that list

2:26

and this one is doing that.

2:27

I'm going to inject one thing radiographically

2:30

and that's so right, as usual.

2:33

But look what it's doing to the clivus, right?

2:35

It's not destroying the clivus, it's remodeling.

2:38

It's almost like somebody just went and cut the clivus

2:40

off right there. You can still see a cortical rim,

2:43

so that tells you it is not a malignant aggressive lesion,

2:46

right? Remodeling, remodeling. Now,

2:49

so some something like this.

2:51

Okay,

2:51

so let's just say that we're talking about a primary

2:54

cellar lesion. Let's say we decided that there's.

3:00

Cyst. The clivus doesn't look right.

3:02

Okay,

3:03

so maybe adenoma, macroadenoma. Now, I'll tell you,

3:08

when I see something

3:11

aggressive like this taking out the skull base,

3:14

I think of prolactinoma, okay?

3:17

Those are very aggressive.

3:19

I remember very clearly somebody coming in when I was at

3:24

the Mayo Clinic and I had to put the patient into

3:26

a halo emergently because a lesion like this,

3:29

I've basically taken out their skull base condyles.

3:33

Okay?

3:33

So when I think of an aggressive lesion so we talked

3:35

before. Before you get into some major commando thing,

3:39

let's be sure to check the prolactin

3:41

and see what's going on here.

3:44

So I think that's the first thing is does

3:47

look like a macroadenoma. It'll do it.

3:51

But make sure you check that prolactin because

3:53

prolactinomas are evasive and that's the

3:56

kind of stuff they'll do, and they can.

4:00

Pretty nasty resect,

4:01

which I know you'll talk about in a minute.

4:02

But I want to clarify one thing.

4:03

I said the lesion was behaving radiographically in

4:07

a non-aggressive way relative to the skeleton.

4:10

What I meant by that was it wasn't malignant.

4:13

It wasn't wiping out the bone.

4:15

But you're so right.

4:16

It does have an aggressive growth pattern or behavior

4:20

other than that, but it's just not a malignant lesion.

4:23

Right. So we're seeing a lesion.

4:26

So this is a 28-year-old with visual loss, right?

4:28

Not something we're going to have to really want to do

4:31

something about. So when you start thinking along and say,

4:35

okay, we got the lesion.

4:36

Now what? So that's when we kind of get back.

4:38

And as I say,

4:39

most of my reports and something like this are going to be

4:42

describing the anatomic relations so that somebody can

4:46

start thinking about that. This thing, for example,

4:48

is in the middle fossa, right?

4:50

Now, we talked about the cavernous sinus.

4:52

So this is way out there, right?

4:54

It's on the lateral side of that carotid, okay?

4:58

It's in the middle fossa.

4:59

So we know. The cavernous sinus is involved.

5:01

Okay.

5:03

The super cavernous carotids are displaced and encased.

5:07

And encased, right? So they're going through the lesion,

5:10

okay. The anterior cerebral complex,

5:12

see that right there is right on top of the lesion.

5:14

So if you're pulling it down from below,

5:16

you got to wonder, well, if I'm going to do that,

5:19

can I do that without damaging the anterior

5:21

cerebral complex? So right there.

5:25

So that is a very important relation.

5:26

You can see right here these anterior cerebral

5:29

complex kind of riding on top of it.

5:31

So that's an important thing to know.

5:33

And also the posterior communicating.

5:35

So here's one going right through the lesion.

5:38

Okay?

5:38

So you're going to have to be looking

5:40

out for these things.

5:41

If we're trying to get rid of this or decompress it,

5:45

at least that's going to be the goal.

5:47

Maybe not completely removal because we

5:48

said it's in the cavernous sinus,

5:50

but if we can decompress the optic apparatus,

5:53

I think transsphenoidal approach is probably going

5:55

to have a role here, but it's going to be tough.

5:58

You're right up against the basilar.

6:00

Right? So you may not want to get all the way back here,

6:04

take some of this out, decompress the optic apparatus,

6:07

and then you still have a transcranial approach,

6:10

depending on how successful you are with that.

6:13

Okay, but this guy, we're not going to let him go blind.

6:15

So something's going to need to be done.

6:17

If it turns out to be a prolactin secretor,

6:20

medically shrinking it down, boy, that's the best option.

6:24

If that's not what's going on here,

6:26

then there are surgical options,

6:28

but it may take more than one.

6:30

But probably because a sellar is so big,

6:32

probably start out from below,

6:34

kind of suck it out from right,

6:36

see what the consistency of it's.

6:38

Like wood, that's not going to work,

6:39

but at least you try to.

6:41

If it's very soft and suckable,

6:44

you may do better than you think.

6:45

And this supercellar portion can prolapse down,

6:48

at least provide some measure compression.

6:50

Yeah, a couple of just kind of summary points.

6:53

There is some anterior extension,

6:56

some presellar extension. As we said, it's intracellular.

7:00

Supercellar. There's retroclival or retrocellar extension.

7:05

And there is infracellar extension.

7:07

If we look at this thing really carefully

7:09

in the axial projection, we follow it.

7:12

Sorry, I'm going up. Let's go down.

7:14

We follow it down, down the carotid.

7:16

Termini are splayed. Let's keep going.

7:18

It's going a little bit off to the right.

7:20

And wow, right there. It's in the Nasopharynx,

7:24

which is unusual.

7:26

And let's look at the Sagittal projection to see if

7:29

that's real. Let's go over to the better side.

7:31

And we can see a clear plane of hypointense separation

7:34

right there. I'm going to make it a little brighter.

7:36

And now let's go over to the other side.

7:38

And you'll see it just wiped out the bone.

7:40

And boom, it's gone right into the Nasopharynx,

7:43

right next to the fossa of Rosenmuler.

7:46

So it has infracellular extension.

7:49

And then finally,

7:50

as I've described to you in other Vignettes,

7:52

instead of the lateral cavernous sinus wall,

7:55

which is right here being a line,

7:57

this black line right here.

8:00

With gray on one side and white on the other.

8:02

It's an interface.

8:03

It's simply an interface with a gray mass abutting it

8:07

so it's no longer a line with white underneath.

8:10

It an obvious sign of cavernous sinus extension.

8:15

Now, one more thing Dr.

8:17

Pomerance was talking about.

8:18

Let me give you the drive back.

8:20

So one thing you might want to do,

8:22

depending on the prolactin things,

8:24

is do you want to biopsy it to figure out what's

8:27

going on before we even get involved?

8:29

Kind of easy biopsy, right?

8:30

It's in the sphenoid. It's really taken out the sphenoid.

8:33

Yeah, I don't want to biopsy.

8:34

You could ENT could do it for you.

8:36

Okay.

8:37

And maybe that'll make you a little smarter when

8:39

you're trying to figure out what to do,

8:40

what the consistency is going to be,

8:42

what other treatment options you have.

8:44

So this is kind of going to present itself right

8:46

out there. So that's another consideration.

8:48

I'll make one other point that I know you love,

8:50

and because this lesion is pretty

8:52

gray and kind of solid looking,

8:55

one of the thoughts you have here is this a weird

8:57

meningioma that's just wiped out the.

9:00

Pituitary gland, which is unusual,

9:01

usually can separate out the gland.

9:03

But I know you love this sign of carotid encasement and

9:06

just kind of compression kind of crushing down the

9:09

carotids and the carotid flow voids

9:11

and their shape is maintained.

9:13

So that really goes against the diagnosis of meningioma,

9:15

as does the enhancement. Granted,

9:17

it's enhancing quite a bit,

9:19

but not as much and not as intensely as a meningioma,

9:22

which has the mother in law sign.

9:24

Likes to come early, likes to stay late.

9:27

Intense enhancement early on. Well, the other thing is,

9:30

well, okay,

9:30

meningioma from where meningiomas start at areas

9:34

of blood supply at particular places,

9:36

meaning the tuberculum sellae would have to be the origin.

9:41

And you don't see a lot of hyperostosis

9:43

stuff like that there.

9:45

You think it'd be worse if it was

9:47

really coming from there.

9:47

Which is kind of where it would have to be started

9:50

to get into the sellar and grow like that.

9:52

So meningiomas location, location, location.

9:55

Right? Because they don't just start all over the place.

9:58

Right. There's particular places.

10:00

And there and the surgery for them is to get to

10:02

the blood supply first, devascularize them.

10:05

So finding the origin of a meningioma is really and the

10:08

tuberculum sellae meningioma is really in this differential.

10:12

So I think when you're reporting this in the conclusion,

10:14

you have to say,

10:16

most compatible with pituitary macroadenoma,

10:19

with other differential diagnostic considerations

10:21

unlikely. And I think it's time to move on.

10:24

Shall we?