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Dr. Shupack.

0:01

This is a 14-year-old man who

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was playing a football game,

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American football, and had a contact

0:07

injury and now has a headache.

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So this case really had nothing to do with the pituitary

0:12

gland, although we saw something kind of strange.

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I just want to touch on some of the variations and

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summarize a few of those that we have discussed

0:20

previously. We said that the pituitary gland,

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which kind of has a U shape, also has a stalk.

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The stalk can be sloped.

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Normally the stalk can deviate to either side.

0:33

We said that the stalk is a little chubbier

0:35

up top and it tapers as you go down low.

0:37

That's fine. That's not a variation, that's normal.

0:39

We also said that in the sagittal projection the back of

0:42

the pituitary gland will have a pituitary bright spot.

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But occasionally,

0:47

in about ten to 20% of the population at a moment

0:50

in time, that bright spot can be missing.

0:53

We said sometimes the top of the gland is flat or

0:57

sometimes the top of the gland is

0:59

a little bit convex upward.

1:01

We also said the gland can physiologically hypertrophy

1:04

at various stages in life, pregnancy,

1:07

during puberty.

1:09

And then we have an interesting variation here.

1:12

We've got slight asymmetry in the amount of marrow in

1:15

the left anterior clinoid compared to the right.

1:17

But on occasion, I've had individuals with hugely aerated

1:22

clinoids so that you have a big black spot right

1:24

here and it can simulate an aneurysm.

1:26

We talked about that in our pitfalls book

1:29

that we generated many years ago.

1:31

But this sagittal projection is kind of strange-looking.

1:34

It's a young guy, and he's got this low signal intensity

1:38

abnormality or pseudo abnormality within the gland.

1:41

So what is going on?

1:43

Right, well,

1:44

actually, I have that pitfall book

1:47

and I'm glad I do because

1:50

it's going to come in handy on this one.

1:52

So this one was something totally unrelated, and then I

1:55

was showing it to one of my colleagues looking at the

1:57

ventricles and stuff like that, and he said, "Well yeah,

2:00

what about that pituitary cyst?"

2:03

I better take another look at that one.

2:05

But this is where the pitfalls book comes in handy.

2:08

So we do see this abnormality here.

2:10

But if we correlate the images, and that's one of the

2:12

themes here, figure out where we are in the gland,

2:15

you can see that that happens to be the medial border

2:20

of the carotid. Okay, so what we're saying,

2:23

and this is also in your pitfalls book, you showed it to

2:26

me my first year here when I missed this problem that

2:30

we're averaging the carotid. And this person,

2:33

if we look at the coronal image,

2:36

it's pretty narrow there. Okay,

2:38

so there's something called kissing carotids

2:40

where the carotids have a variation.

2:42

They can be far apart or narrow, and in this case,

2:46

that's about 5 mm. They're pretty narrow.

2:48

It's pretty narrow. What should they be?

2:50

Well, in order to do a transsphenoidal surgery,

2:53

you need about a centimeter.

2:55

So I hope this guy never needs that,

2:56

because this is another thing that you need to report.

3:00

If you're talking about a sellar or suprasellar lesion that

3:04

the surgeon is going to be thinking about because if

3:06

you try to go in here and there are kissing carotids,

3:10

there's a good chance of ending up with a carotid

3:11

injury and not getting your tumor out.

3:13

I mean,

3:13

I'm a little embarrassed about that because until I met

3:15

you, I knew about the entity, I knew about the pitfall,

3:18

but I did not know about the surgical significance

3:20

of it. Right. So thank goodness we met.

3:22

Right? Well, yeah,

3:24

that's something you don't ever want

3:25

to experience if you can avoid it.

3:29

We talked earlier about aeration of the sphenoid.

3:32

You have to get access to the sellar

3:34

through an anterior approach.

3:36

But you also have to have a sella that's wide

3:38

enough if you actually work through,

3:40

particularly if you have a suprasellar portion.

3:42

Okay.

3:43

So the size and shape of the sella and the structures

3:46

around it are going to be sort of one of the themes of

3:48

our case review. I want to make one other point.

3:50

This is a great pitfall because many of you out there

3:53

are wondering, well, the carotid has a flow void.

3:56

It's black. Why isn't this thing black?

3:59

And the reason is you're right in the wall of the

4:01

carotid. You're not actually imaging the lumen.

4:03

You're along the free wall of the carotid

4:06

volume averaging with the adjacent pars,

4:09

the stalks of the pituitary gland.

4:11

Then you keep going over to the other side

4:13

and you've got the exact same thing.

4:14

You're along the inner free wall of the carotid,

4:17

not in the lumen.

4:17

If you're in the lumen, volume averaging the lumen,

4:20

then it'll be a black spot.

4:21

But this time it's a gray spot because it's volume

4:24

averaging of the kissing carotid walls.