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Dr. Schupack, 53-year-old woman with headaches and dizziness.

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I've got for you a sagittal T1 without contrast,

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a coronal T1 without contrast,

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and an axial T2 without contrast showing a fluid

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fluid or potentially a blood fluid level.

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Now, one point I'd like to make before you talk about

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this case is that it's a combined lesion.

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And what I mean by that is there's definitely supra cellular

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involvement and there's definitely intracellular involvement.

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And the classic combined lesion would

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be the figure of eight macroadenoma.

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Another example of a combined lesion that will infiltrate where you

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can't separate the pituitary out from the supra cellar

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component would be a germinoma.

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But germinomas are not bright on the T1 weighted image,

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so that's going to heavily influence your differential diagnosis.

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Germinomas are solid, they're pretty smooth, they're pretty gray,

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and in fact, they're so densely packed with big polygonal cells.

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That they're hyperdense on CT.

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That's a very important point.

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And they are ISO intense uniformly on MRI.

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This is neither of those.

1:10

It's not uniformly ISO intense.

1:12

Yes, there's some ISO intensity,

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but it's got this blood fluid level,

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and it's got the wrong T1 signal intensity.

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When you see high signal T1 in the pituitary gland,

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you're thinking fat, you're thinking cholesterol,

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you're thinking cholesterin,

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you're thinking about dermoids, craniopharyngiomas, and perhaps this

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abnormality, which is a very important one to pick up right away,

1:35

right?

1:36

So if any of you should have the misfortune of taking the

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neurosurgery oral boards, you are going to see this case, okay?

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And there are going to be three questions that are going

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to be asked. First one, they're going to put it up.

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Diagnosis, but pituitary apoplexy, okay?

1:52

Hemorrhage into the pituitary.

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Then the next question. Treatment, decompressive surgery.

2:00

Okay, question three. When? Answer today.

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Okay. Surgical emergency. All right.

2:08

A surprising number of these patients will end

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up dying without decompressive surgery.

2:13

Now,

2:13

it depends a little bit on the presentation.

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Some of them have subacute presentations,

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but the acute presentation a classic presentation.

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Altered mental status, ophthalmoplegia, acute onset, a headache.

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They can get brain stem compression.

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I've seen it get vasospasm.

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Okay, so this is a phone call for sure.

2:34

Neurosurgical consultation for sure. And as I say,

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surgery today is the standard.

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Now, another issue is okay,

2:42

so you have this patient in your scanner.

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You're sitting back there on the monitor, sizing it up.

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Tech comes back and says, Doctor,

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could you take a look at this patient?

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He's not looking very good.

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And I took the blood pressure.

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It's 80.

2:57

Okay, what's the deal? Okay.

3:00

It's profoundly hypopit. Solu-Medrol 100 IV now.

3:05

Okay. Because these people will go out on you, all right?

3:08

So clinical issues,

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you're their doctor while they're in the scanner, for sure, right.

3:12

You can call anybody you want, but there's a treatment for that.

3:15

So being familiar with this and the clinical implications,

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because these people will go out on you.

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Well, I mean,

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I hate to go anecdotal on an educational vignette like this,

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but my first encounter with this was 25 years ago.

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A colleague's father, who needed back surgery,

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waiting for the surgery. They go up to get him.

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He's uptunded. They bring him down.

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They do an MR scan on him.

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He's got one of these.

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And he had profound depression of cortisol,

3:41

profound depression of thyroid hormone.

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And it took about eight days in the ICU to get him back up to speed,

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and he was in the hospital when this was detected.

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So you've got to pick up pituitary apoplexy.

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It's got to be right at the top of your list when you have

3:55

an adult with a big lesion that has this high signal.

3:58

And not only is there a fluid.

4:00

Fluid level. It's a sandwich.

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It's bright and then it's gray and then it's dark gray.

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And so that layering effect very unusual with most lesions except

4:11

for hemorrhagic adenomas bleeding. In the pituitary,

4:14

I suppose you could see three layers in a dermoid.

4:17

I haven't usually two layers,

4:20

but this one is Pituitary apoplexy now also, so the cell is big.

4:24

So there's probably a pre-existing macroadenoma.

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That's when you're going to see them.

4:28

Now you can also get these non-hemorrhagic.

4:31

That is a big pituitary.

4:33

Infarct has also been described in it.

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And diffusion restriction,

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if you're wondering about that and you're saying, hey,

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what's going on here? They have this syndrome.

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And the diffusion image has been shown in some studies to be very

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helpful for the infarct one, which I think is less common.

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But I think I've seen it a couple of times.

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Sure, you're getting cell death.

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You also have a very kind of liquefactive viscous center to it.

4:56

So diffusion restriction is helpful.

4:58

And you're going to see a lesion.

5:00

Practice, maybe on an axial CT.

5:02

You'll have some hyperdensity on CT.

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The patient is slightly obtunded or acting funny,

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just like you said, and you don't think about it.

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You think, well, maybe it's a meningioma because it's hyperdense,

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or maybe it's an aneurysm.

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You have time to wait.

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Well, you really don't.

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So it's important that you assess the character of the density.

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Is it blood? Is it calcium on CT,

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or is it also important if it's calcified.

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You look. Is it stippled calcification?

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Is it chunky calcification?

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Is it arc-like calcification as in an aneurysm?

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Or is it just hyperdense?

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And there's absolutely no calcification,

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which would be the case in this scenario.

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So you're on ER call, you're reading some head CTs.

5:44

You better have that in the back of your brain when you

5:46

see a suprasellar mass right smack dab in the midline,

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that's somewhat hyperdense. And a 50-year-old.

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And they come in and they are just simply physically exhausted,

5:56

depressed in their hypopit. Shall we move on?

5:58

Yeah, let's.