0:00

Very unfortunate case. Dr. Schupack. 22-year-old girl,

0:03

she's got cerebral palsy. Prolactin is elevated,

0:07

and she has this large intra- and suprasellar mass,

0:11

probably of sellar origin. It is of sellar origin.

0:13

We know the diagnosis. It's a coronal T1C-minus,

0:16

non-contrast, sagittal T2 non-contrast, of course,

0:20

and an axial overview of the brain.

0:23

And I'm going to scroll these and ask you,

0:26

what do you do? This is a monstrous lesion, right?

0:30

So what you're going to hear from the clinician is, hey,

0:35

do I even need a radiologist?

0:36

Everybody knows we got a problem here.

0:38

Okay,

0:39

but what do you the radiologist can really be helpful

0:42

in thinking through what's going to happen next.

0:46

Now, the first thing that Dr.

0:47

Pomerance mentioned is elevated prolactin.

0:51

And the next question there is how elevated?

0:55

Because there are two ways to get elevated prolactin.

0:58

One would be a big mass with a suprasellar component

1:01

with the deformation of the pituitary stalk,

1:04

so-called stalk effect. Okay?

1:05

So that will elevate your prolactin, but not that high,

1:09

meaning indirect compression. Indirect compression.

1:12

So let's say if you have a prolactin with this lesion

1:15

and it's 100 or something like that, you would say,

1:19

well, okay, it's probably stalk effect,

1:21

because a lesion like this,

1:22

if this is a prolactin-secreting tumor,

1:25

is going to have a prolactin in the thousands,

1:28

this gigantic lesion, cavernous sinus extension.

1:31

And if you can prove that this lesion

1:33

is a prolactin-secreting tumor,

1:36

that is prolactin way above what

1:38

stalk effect would explain.

1:40

You have a medical treatment for this.

1:42

I have treated some of these that look just this

1:45

bad with parlodel, and it almost disappears.

1:48

So before you get involved,

1:50

we got a real complicated surgical problem here.

1:53

That's the first thing we want to be sure we're

1:55

not getting off on the wrong track.

1:57

You could save her life.

1:58

And in fact,

2:00

she died from infectious complications of this surgery.

2:03

So she might have been a candidate if her prolactin

2:06

level was very high for medical therapy.

2:08

Unless this case is a tragedy.

2:10

Probably not.

2:12

I'm assuming they did all that,

2:13

but that's the step you do not want to miss.

2:16

Sure. Okay. Now,

2:18

let's assume for the moment that we don't have reason

2:20

to believe it can be treated medically.

2:23

And then the question is, well,

2:24

could it even be treated surgically?

2:26

So in order to do that,

2:30

what we're trying to figure out is thinking

2:33

like the clinicians are going to

2:37

what surgical approaches are available?

2:40

And most of my report on a lesion like this is going to

2:44

be describing the anatomic relations to the lesion.

2:48

Okay? That is, is it accessible, for example,

2:52

through the sella we just described

2:55

that the sella is big.

2:56

Okay?

2:57

So transsphenoidal approach at least could be part.

3:00

Of the surgical solution. If you had a tiny sella, right,

3:03

then you can't work through the sella,

3:05

and it's probably not an adenoma that's going to change

3:08

that approach. Now, what are the other ways you can go?

3:11

Well, you can kind of go laterally,

3:13

so-called pterional approach.

3:15

The same one you would use for an aneurysm

3:18

with a temporal craniotomy right here,

3:21

that's the pterion right there.

3:22

That's the pterion right there based on the pterion

3:25

burhole because it gives you access to the anterior and

3:28

middle fossae if you put your burhole in the right

3:30

place. Okay, so very common neurosurgical approach.

3:33

Now in this case,

3:34

you got something else to take into account,

3:36

which would be this middle fossa cyst.

3:39

So you're going to say, well, actually,

3:41

the things in the middle, which side do you go from?

3:44

Okay, well, the fact that there's an issue over here.

3:47

You want to protect the good side.

3:48

Okay. So you might actually go this way because, one,

3:51

you have less brain to go through at risk.

3:55

So you want to protect the good side.

3:56

So we're thinking of sides already.

3:58

And you could even deal with the arachnoid cyst

4:00

at the same time. Well, that's correct.

4:03

Yeah, you can drain the arachnoid cyst.

4:05

It does have some mass effect.

4:06

Another thing is Dr.

4:08

Pomerance mentioned obstructive hydrocephalus. Okay.

4:11

So the first thing you do before you start doing any

4:13

major craniotomy is you might want to deal with that.

4:17

That is put a shunt or an extraventricular drain in,

4:19

because that's what could kill the patient right off

4:22

the bat. If there's obstructive hydrocephalus,

4:24

it's not that severe at this point,

4:25

but if that's developing, okay,

4:28

that's going to have to be on your list and something

4:32

you would want to discuss with the clinician

4:34

if you think that's present,

4:35

because they could be cogitating about what are we

4:38

going to do with this thing in the meantime?

4:39

The patient's going out because of progressive

4:41

obstructive hydrocephalus. Yeah.

4:43

And the ventricles are a little big,

4:44

and the temporal horns are definitely too big for early.

4:48

The third ventricle is wide.

4:50

Okay, so we got that.

4:52

Now another approach is this thing is

4:54

way up in the ventricular system.

4:57

So approaches are going to be there's going

4:59

to be lateral approaches, transsphenoidal,

5:01

but even this going this way.

5:03

Okay.

5:03

So sometimes multiple approaches are necessary

5:06

to get out a big lesion like this.

5:08

This one might be in multiple stages.

5:10

You might start transsphenoidal, get this portion out.

5:13

Hopefully a lot of this could drop down,

5:15

basically suck it out, suck it down.

5:16

Depending on the consistency of it,

5:19

it may kind of prolapse down,

5:20

and you could do a much better job at decompression than

5:23

you think you might be able to, just looking at it.

5:25

Okay, but then, okay, so you do that, that doesn't work,

5:29

then you get the tyronal approach.

5:30

Which direction? And then let's say in this case,

5:33

it doesn't have a large ventricular component,

5:37

but there is transventricular approaches.

5:38

So sometimes there's multiple approaches here,

5:41

but the first thing is,

5:42

is there a non-surgical treatment?

5:44

And what are our options?

5:46

And then trying to make all these decisions.

5:48

So that's what the radiologist can do.

5:50

You can say, wow, you got to look for your carotid.

5:53

This thing is related to the anterior cerebral.

5:55

It's doing this to the basilar.

5:57

Okay. Those are all things the surgeon is going to

6:00

take into account, and that is the value of your report.

6:03

In an instance where everybody knows there's a problem,

6:05

your grandmother can see it.

6:07

Okay.

6:07

The radiologist has a major role because you are the

6:10

gross anatomist that can point out all these things and

6:13

help the treating physicians think through what options

6:17

really work. I have two questions for you.

6:19

First of all, my grandmother could have seen this one.

6:21

And my two questions are,

6:24

do you prefer to go on the right side,

6:27

all other things being equal because the

6:29

speech error is on the left side?

6:31

Yeah.

6:31

Generally speaking, you go from the right.

6:33

Now in neurology, you folks may have rotated through it.

6:37

You always ask what handedness the person is, right?

6:40

25 year old left-handed.

6:42

Why? Okay,

6:43

because it has to do with speech localization.

6:45

So if somebody's left-handed,

6:47

there's going to be a percentage of those people that

6:49

have speech on the right side or bilateral dominance.

6:52

But that's the reason. Okay?

6:54

So generally speaking,

6:55

you tend to go from the non-dominant hemisphere because

6:58

of speech. Now, there are a couple of things,

7:00

situations that can change that.

7:02

For example, an aneurysm in the anterior communicating artery.

7:06

Its direction that it's pointing in.

7:08

You want to go to the neck instead of being runny

7:10

right into the dome. Sure.

7:11

Okay,

7:12

so that may change your sightedness,

7:14

even if they are right-handed.

7:16

Sure.

7:16

Something like that never occurs to radiologists

7:19

unless you hear it from a neurosurgeon.

7:20

Right. So the side is very important,

7:23

but basically what you're trying to do is

7:26

you want to protect the good side.

7:27

Okay.

7:28

If there's a problem already,

7:29

go through that side where there's already an issue and

7:33

figure out what am I going to see going in that I can

7:36

protect and what am I going to run into on the other

7:38

side that I might not see until it's too late.

7:40

That's super interesting because my initial instinct was

7:42

stay away from the bad side because you've got that

7:45

arachnoid system away. So that's super informative.

7:48

My second question,

7:49

I put up this sagittal T1-weighted image.

7:51

The sphenoid is kind of hyperdense.

7:54

There's a bit more bone than you usually see

7:56

to get through to get into the sella.

7:58

So is that worth commenting on?

8:00

Would that preclude an infrasellar approach?

8:02

I don't know if it's going to preclude it in this case,

8:05

when the basisphenoid is totally nonaerated,

8:08

I think it's going to make it harder.

8:10

Like, I probably would ask for ENT and do a more extensive

8:15

transphenoidal approach rather than just a limited trans

8:17

nasal because you're going to have to get a

8:19

drill or at least be prepared to do that.

8:22

That is a really important worth commenting.

8:24

Right.

8:25

Meaning whenever you're thinking about these approaches,

8:27

you have to comment on the cavernous sinus

8:30

extension, aeration of the sphenoid. Where are the carotids?

8:33

We saw over here that the carotids are widely

8:36

spread by this lesion, so kissing carotids.

8:38

But when you're starting to think about the approaches,

8:43

that's one of the things that's going to fit into the

8:46

surgical equation that you'll be making a real

8:48

contribution to the surgeon's thinking, okay, great.

8:51

So here are the carotids.

8:52

They're nice and wide.

8:53

We've talked about the different surgical

8:56

approaches to this lesion.

8:57

We've talked about some of the pitfalls of this lesion.

8:59

We talked about some clinical aspects of this lesion.

9:02

This lesion was resected. Unfortunately,

9:05

it didn't go well. And in an accompanying vignette,

9:07

we're going to talk about the differential diagnosis of

9:10

suprasellar masses with intrasellar involvement.

9:13

So let's do that, shall we?