0:00

Dr. Shupack,

0:01

this is a 37-year-old woman who's had intractable

0:04

migraines since childhood.

0:06

I have for you an axial T2 spin echo.

0:09

I could do a little scrolling,

0:10

but it wouldn't do a lot of good because the lesion is

0:12

pretty small. It's right there and pretty bright.

0:14

There's the Meckel's cave on the patient's left side,

0:19

And then...

0:20

Sorry, on the right side.

0:21

And then here's the sagittal projection,

0:23

the sagittal T1,

0:24

demonstrating the mass right

0:26

there in front of the pituitary bright spot,

0:29

but perhaps behind the pars distalis.

0:32

And then here is a coronal flair in which

0:36

you really don't see all that much,

0:38

even though you're really close to the lesion.

0:41

There's a lesion right there.

0:43

And then as you move forward,

0:45

here's another area of interest right there.

0:47

So I'll let you comment on this little ditzel,

0:51

Right.

0:51

Yeah. So we're kind of into ditzel hood now,

0:54

and the reason I would say that is,

0:55

you know,

0:56

one of the first decisions you want to make,

0:57

is this something that's going to require

0:59

treatment or what?

1:00

So we have a lesion,

1:02

but there's no mass effect in the optic apparatus,

1:05

there's no cavernous sinus thing,

1:08

and we didn't get, on the history at least,

1:10

any evidence that it's endocrine, so probably not.

1:12

So we want to kind of phrase things and cast it

1:16

in a way that, you know,

1:17

nobody's going to get too worked up,

1:19

particularly the patient who may get the report

1:20

before the doctor does,

1:22

you know, as to how we play this.

1:24

And we know that 15% to 20% of all normal MRIs

1:27

either have a "filling defect",

1:31

an area that's a little darker, a ditzel,

1:33

and even a little cystic area.

1:36

And those cystic areas can be non-functioning

1:38

microadenomas that are incidentally discovered,

1:40

or they can be non-neoplastic cysts,

1:43

also known as pars intermedia cysts,

1:45

Rathke cysts or intra pituitary cysts.

1:48

Well,

1:49

and you know, you delineated earlier

1:52

the sections of the pituitary, the anterior, the neurohypophysis,

1:56

but there's a third one, which is the pars intermedia,

1:58

and...

1:59

which is in between the two,

2:01

kind of right behind the stalk.

2:02

And that's kind of right where this is.

2:04

Sure.

2:04

Okay. And also I would point out that,

2:06

okay, so there is a little mass there.

2:08

But you know,

2:09

not much mass effect.

2:10

See, this is the pituitary tuft which we talked about.

2:13

So this is right in front of the thing,

2:16

but, you know, very little effect on it.

2:18

And that's because this pars intermedia

2:19

is sort of a potential space.

2:21

So something can kind of happen a little bit in there,

2:24

but maybe not affect what's in front and behind as much.

2:27

That's pretty small.

2:27

That could help you out.

2:28

That's pretty small.

2:29

And anatomists actually group it with

2:31

the anterior pituitary gland.

2:33

Right.

2:33

So the anterior gland would be pars tuberalis,

2:36

part which we don't see right now.

2:37

The pars distalis.

2:38

Pars distalis, right there.

2:40

And then the pars intermedia

2:42

comprise the anterior pituitary gland.

2:44

The posterior gland made up of the median eminence

2:47

right about here, the stalk, and then the bright spot,

2:50

or pars nervosa.

2:51

So you got three and three just to make it very clear.

2:54

So back to this cystic thing.

2:57

Right.

2:57

So, I think we kind of...

2:59

we got a location,

3:00

we got a signal characteristic,

3:02

we got a lack of clinical.

3:04

So we're kind of kind of phrased this,

3:06

of saying, you know,

3:09

pars intermedia cyst favored,

3:10

finding is of uncertain relation to...

3:13

you know, there was a litany of complaints here,

3:15

headaches and other things.

3:16

You know, so we want to make that clear

3:18

that it's a common finding,

3:20

but not something that's going to require some urgent

3:23

surgical treatment and that the

3:25

relationship is unclear,

3:27

so that the clinician can take that to the patient

3:30

and really pretty much reassure them,

3:32

at least on that score.

3:33

And I might even say that the finding is unlikely to

3:36

be related to the patient's clinical syndrome in this scenario.

3:39

Right.

3:39

Let's go after another one, shall we?

3:41

Yup.

3:42

Okay.