0:00

Let's look at this middle-aged female in her 40s

0:04

with a history of pituitary adenoma and weight gain.

0:08

I've got before you, Dr. Schupack,

0:11

a Sagittal T1, non-contrast,

0:13

an axial T2,

0:14

and then the matching Sagittal T1 with contrast,

0:17

which I'll scroll a little bit and allow our viewing

0:20

audience to have a look at what we've got.

0:23

I'll also scroll the T2 a little bit up and

0:25

down so you can see what we've got there.

0:28

And we do have an intermediate

0:29

signal intensity abnormality,

0:32

seemingly in the suprasellar region.

0:36

And I'd like to ask you your thoughts on this case,

0:39

since it already has a presumed diagnosis, right?

0:43

Well,

0:44

there is a presumed diagnosis and it's

0:46

an important case clinically, right?

0:48

Because as we talked about endocrine,

0:51

there's some history that could be endocrine.

0:53

So you give some thought to that.

0:54

But also mass effects.

0:55

So we have mass effect on the optic apparatus.

0:59

So there's conceivable that at some point,

1:01

treatment, maybe surgical,

1:03

is going to be considered, perhaps not now,

1:05

depending on the patient's visual status,

1:07

but it's going to be followed for that reason.

1:09

So if you're thinking that there might be treatment,

1:11

you've got to be pretty sure about the diagnosis.

1:14

And this diagnosis of adenoma,

1:16

I think I'm going to question that.

1:18

And the reason I would say that there's a couple of

1:20

things that we have discussed earlier on the earlier

1:23

segments. The sella is not too big, you'd think?

1:26

A big suprasellar mass. And also,

1:30

I think we talked about this earlier,

1:32

we're talking about parasellar structures.

1:35

And so the tuberculum sellae is right here.

1:39

And tuberculum sellae,

1:41

remember we talked about skull-based lesions,

1:43

meningiomas, they come in certain spots.

1:46

They don't just show up anywhere, right?

1:48

They have certain spots.

1:49

And the tuberculum sellae is

1:51

a really good spot for it.

1:52

So I think that's part of the diagnosis because you

1:55

couldn't really work through this sella

1:56

to get here anyway. So the question is,

1:58

if the cella is not enlarged and you have a

2:00

suprasellar mass, is it something else?

2:02

Well, here's another thought.

2:04

It looks like there might even be a cleavage plane

2:06

right there between it and the underlying

2:09

pituitary fossa. Now,

2:12

you can get meningioma lesions that

2:14

arise from the tuberculum sellae,

2:16

but you can also get them from the diaphragma sellae,

2:19

directly from the diaphragm.

2:20

You can also get them from the dural covering over

2:22

the anterior clinoid processes we talked

2:25

about in other vignettes. The big five.

2:27

The big five,

2:28

Kahuna Meningioma being number one when

2:31

you get in the suprasellar region.

2:32

But the others are meningioma, aneurysm,

2:35

craniopharyngioma, and astrocytoma,

2:38

a little bit different than if

2:39

you were in the pituitary space,

2:41

where you would be thinking about things like

2:42

pituitary hyperplasia, hydrocephalus,

2:46

craniopharyngioma, and then pilocytic astrocytoma.

2:49

Which leads me to one other thought.

2:51

You should be deciding in the audience

2:53

if this lesion is intra or extra-axial.

2:56

If it's intraaxial,

2:57

you'd expect it to be coming from.

3:00

Things like the optic chiasm right here or the

3:02

hypothalamus or even the third ventricular region,

3:06

but it's not. It's extra-axial.

3:08

It's probably separate from pituitary gland.

3:11

And it's got this sort of little point like it's

3:14

growing flatly along the dural surface,

3:17

almost like the dovetail sign that we see in the

3:20

middle fossa when we have a middle fossa

3:23

meningioma one along the petroclinoid ridge.

3:27

Right? Now, another thing about it is you'd say,

3:29

well, they did endocrine testing.

3:31

Well, if that's abnormal, well,

3:32

I could even imagine the proximity of the stalk

3:35

if the prolactin was up a little bit.

3:36

Now, if it's over 100,

3:38

then you got to really think seriously about a

3:41

secreting lesion. But let's say it's 40, 50.

3:43

That could be extrinsic. Now, the other question is,

3:46

since we're entertaining this

3:47

diagnosis of meningioma,

3:49

is there anything else we could marshal in support

3:51

of that? One is the patient's a female.

3:54

Let me make that a little bigger for you so

3:56

everyone can see it. So the patient's a female,

3:58

so they get meningiomas.

4:00

They have hormone receptors,

4:02

but also there's another meningioma.

4:05

Okay, so the weight of the evidence,

4:08

we're starting to get some support for that idea.

4:10

And that's really important because they decided

4:12

this was an adenoma and they're going to treat it

4:14

at some point. Transphenoidal, wrong way to go.

4:17

Right. The lesion,

4:18

you're not going to be able to get to it.

4:19

The lesion is not from there.

4:21

That would be a mistake.

4:22

Okay,

4:22

so really critical differentiation

4:25

to make for the clinician.

4:27

And it turns out the prior diagnosis of pituitary

4:29

adenoma was made by another radiologist at another

4:32

institution. It wasn't pathologically proven,

4:34

so it could lead you down the wrong path.

4:37

Of course,

4:37

you can get multiple meningiomas

4:39

as part of a phakomatosis,

4:41

either meningiomatosis or neurofibromatosis

4:44

type two that wasn't present here.

4:46

And then if we go back to the T two,

4:48

just a few other takeaways to help support

4:51

your diagnosis. Yes, it's true.

4:53

Macroadenomas look like gray matter,

4:55

but meningiomas look pretty close to gray matter,

4:58

too.

4:58

They can even be a little bit darker than

5:00

gray matter. They're usually firm.

5:02

You don't get a lot of cyst

5:03

production in meningiomas.

5:04

You do in suprasellar lesions like craniopharyngiomas.

5:07

You can get them in macroadenomas,

5:09

occasionally get some microcysts, and of course,

5:12

meningiomas will calcify.

5:14

That may be hard to see on MR, easier on CT,

5:17

and they may produce a dural or skeletal reaction,

5:20

which is not the case with a suprasellar

5:22

craniopharyngioma or macroadenoma.

5:25

So this was misdiagnosed by someone else.

5:27

They missed this separation.

5:29

They miss this linear growth pattern along

5:32

the dura in the tuberculum sellae.

5:33

This is suprasellar meningioma.

5:35

Should we move on and do another one?

5:37

Yes, let's do it.