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Suprasellar Meningioma

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Dr. Shupack, this is 61-year-old man,

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has known prostate carcinoma,

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which by the way is a lesion that can metastasize to

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the brain and have a very kind of smooth, firm,

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intermediate signal intensity when it's outside

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the skull. But when it's in the skull,

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it's going to be really, really dark on most sequences.

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That's why it's the penultimate sclerotic metastasis.

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Now, this person has a known cerebellar meningioma.

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The symptoms that brought him in here are kind of vague.

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We have a sagittal T1-weighted image right here that

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shows a mass near to the cellar. There's the cellar,

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there's the mass. We've got a T2 fast spin echo,

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there's the mass and it kind of makes

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this little snowman effect.

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Is it connected to this structure underneath or not?

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In other words,

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is it another meningioma or is it an adenoma?

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That's probably the main question to be answered.

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And then we also have the coronal T1 C+ image to

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go along and. So what's the diagnosis here?

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We probably had fired our gun a little bit by

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saying there's been a prior meningioma.

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So that makes it more likely.

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But why is it a meningioma? Right, well, first of all,

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there is a dural tail, as you mentioned,

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but it's in a classic location tuberculum sella. Okay.

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So one of the that is really important,

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where you think it is coming from when you talk

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about a meningioma, where is it coming from?

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And the reason for that is that one of the main tenets

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of meningioma surgery is that when you're operating,

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you can't just dig into the thing or you're going to

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have a long day. You have to devascularize it first.

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You get to the blood supply first.

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So you're not coming from underneath this time? Well,

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you are. You're going to go right here. Usually,

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there's going to be some hyperostosis. Okay.

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So basically what you try to do with these things

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is kind of get under it, cut it off,

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and then get into it once you've gotten the blood

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supply. So meningiomas will come in classic locations.

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Convexity falx, olfactory, grooved, tuberculum.

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Classifying in that way is important because that tells

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them how they're going to have to approach it to get to

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the blood supply more than the mass itself. Yeah.

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Let me ask you a real question,

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just to interrupt you for a second.

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If I showed you this case with all the other sequences,

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would you then tell me,

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I want a CT before I operate as a neurosurgeon.

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A CT could be interesting for calcification.

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Meaning if you think it's going to be like a rock

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and you may have to prepare yourself for that,

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a CT might be very useful.

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Does the amount of sphenoid bone or

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thickening does that affect what you do?

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Or do you want to know that ahead of time?

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I think you do want to know it.

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And the reason is sometimes what you'll see is an

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area of, like, a nodular thickening. You say,

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that's where I'm going, because you'll drill that off.

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You drill through the bottom of it and then you

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vascularize it. And then when it's kind of floating,

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no blood going into it.

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You're going to have an easier time taking it out.

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But this one is going to get treated because

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it's got optic apparatus. Depression. Okay?

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So next thing we say is, okay, diagnosis meningioma.

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Fine.

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Now we have to move on to what's the treatment going

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to be. So you can go from either direction.

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You tend to go from the nondominant side,

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but this would usually be the right side,

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the right side, at least in a right-handed individual.

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But this one has a Sphenoid cyst. The question is, hey,

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I got a little shorter.

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So you're going to think about it. Now,

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you still may end up going from the right,

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but it's a good thing to say. Okay.

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It's going to have to be treated. How?

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Because then you're going to make comments that,

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for example,

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relationship to the anterior cerebral complex is an

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important thing because they have

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to take that into account.

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They're going to have to peel that right off the top

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of this. Meaning you're going to get in there,

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there's going to be an arachnoidal plane,

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you're going to want to lift that

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up away from the thing.

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So all these things that the surgeon

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is going to be thinking about,

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you want to be thinking about and put it in your report

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so that you're part of the team devising this treatment.

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Sure.

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Now there's probably three compressive

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structures that you're interested in.

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Already pointed out probably the most important one,

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which is the optic apparatus,

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and that's a good reason to operate on it.

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Another one would be what's happening with the carotids.

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Now, sometimes the carotids will get splayed,

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pushed apart, and that can happen with any mass.

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It happens with arachnoid cysts.

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But one thing meningiomas like to do is they like to

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grow in a kind of a lipidic sort of surface-like

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fashion, so they can wrap around the carotid,

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but when they wrap around,

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they can choke the carotid and narrow the carotid.

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So you really got to look at the size of

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the carotid arteries on either side.

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And then the last compressive thing you want to check is

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the pituitary gland, because you can get stalk effect,

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you can get prolactins up to 100,

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almost never above 150 nanograms per mL.

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But if you get really severe compression,

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then you can get pituitary insufficiency.

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So pituitary gland compression, keyismatic compression,

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compression and narrowing of the carotid arteries.

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Those are three key things that you want to put on your

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checklist. And then this lesion is. Pretty smooth,

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gray lesion.

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You can see it's slightly different in

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signal from the pituitary gland.

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It's slightly different in enhancement from the

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pituitary gland. It has a plane of separation.

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But there really aren't very many things that go

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supercellar that are this gray and this smooth

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on every sequence. And, you know,

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they really boil down to adenoma macroadinoma.

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We've already established it's not because we've seen

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the plane of separation. Then you've got meningioma,

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and then after that, it's very slim pickings.

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I have seen germinoma do this.

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I've seen a sarcoidoma do it.

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But other than that and lymphoma other than that,

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very few lesions are going to give you this smooth,

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gray appearance. So it's almost definitive.

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It's almost diagnostic empathic mnemonic for a

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meningioma. Shall we move on? Yes, let's do it.

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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