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Dr. Shupack.

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We've we're back with our 22-year-old woman with

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hyperprolactinemia. She's got cerebral palsy.

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She's had this surgically excised.

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And I've got a coronal dynamic T1-weighted image

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with contrast. You see contrast not on board,

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contrast arriving early and pretty intensely enhancing,

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but a progressive wash-in of the contrast.

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Then we go to the next slice and so on.

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Some cystic components.

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Clearly a supracellar mass of intrasellar origin.

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A proven pituitary macroadenoma.

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Here's the Sagittal T2 fast spin echo.

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Here's the coronal T2 fast spin echo.

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We've already established that she's got an arachnoid

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cyst and a stated she has cerebral palsy.

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But that's not what I want to talk about.

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I want to talk about supracellar masses.

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Now, this is supracellar mass with an intrasellar origin.

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And that leads us to the big five,

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those of you that have been to Africa, the big five: leopard,

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lion, elephant, Cape buffalo, and rhino.

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The big five in the pituitary region,

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in the supracellar region, specifically number one,

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the big kahuna, is macroadenoma.

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Somewhere between 35 and 50% of supracellar masses.

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Approximately 10% encompass the other four

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of the big five: meningioma, aneurysm,

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which is going to have flow void or pulsation mismapping.

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You can hook it up to a vessel.

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Craniopharyngioma may have cysts, this one does.

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May have calcium, this one doesn't.

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May have blood fluid levels.

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I'm not going to show you right now, but this one did.

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May have some blood in it, some machine oil in it.

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Very heterogeneous. This one is heterogeneous.

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So you'd be thinking craniopharyngioma except

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that this thing is arising from the sellar.

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It blends with the sellar.

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It's indistinguishable from the sellar down low,

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there's no plane of separation.

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And then finally,

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the last one is Hypothalamic chiasmatic astrocytoma,

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which is going to arise up in here and is not going to have

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this blended appearance with the sellar structures.

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Then you get into some less common entities.

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Dilated third ventricle. Well, it's not CSF.

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Arachnoid cyst with mass effect.

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It's not CSF. Neurocysticercosis never be this big.

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Rathke's cleft cyst, they can be 3 mm up to 3 cm,

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but not this big and not this solid.

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Neurosarcoid, well, not cystic. It's an infiltrative lesion.

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There's usually enhancement of the meninges,

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so that wouldn't really fit.

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It's also pretty darn rare.

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Eosinophilic granuloma likes the stalk.

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This isn't a primary stalk lesion.

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Then you get into germinoma intense enhancement,

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which this one has, but more amorphous,

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ill-defined enhancement for germinoma seen in men and women.

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Men perhaps a little more common dermoid cyst.

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You're going to have fat, you might have fat fluid levels.

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These are really uncommon to rare lesions.

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So that wouldn't really fit here statistically.

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If you're just going to guess,

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but also not enough fat to consider

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the diagnosis of dermoid.

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And sometimes these will rupture and give you chemical

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meningitis and then lipoma looks like fat,

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then you get into really weird stuff after that.

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And I'm not going to take all those on

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things like lymphoid hypophysitis,

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which occurs in pregnant women, pituitary apoplexy,

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or an infarct with a giant area of hemorrhage

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and a fluid level epid dermoid cyst.

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It's a big proteinaceous cystic mass, pituocytoma,

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which can occur in the pituitary stalk,

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and then some other real weird OMAS that we're not

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going to cover in our full list right now,

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but that's the differential diagnosis of supracellar masses,

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give or take a few, like tuberculoma, pituitary abscess,

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cavernous malformation, leukemia, lymphoma, ectopic,

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neurohypophysis, etc.

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Let's stop right there and we'll move on to our next case,

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shall we?