0:01

Dr. Schupack, I've turned to you many times,

0:03

you know, to discuss with you my consternation

0:05

about the pituitary stalk.

0:06

You know, there's a lot of subjectivity

0:09

in evaluating its size, its thickness,

0:11

its enhancement pattern.

0:12

I'm starting out with a coronal subtracted dynamic

0:16

T1 high-resolution MR.

0:19

You could see we're in the front of the gland.

0:20

We're catching a little bit of the pars tuberalis

0:23

and then this little enhancement

0:25

in the gland called the pituitary tuft,

0:26

which I know you're going to talk about,

0:29

but I don't want folks to get confused with this pars

0:33

tuberalis because it's kind of nodular looking and your

0:36

first reaction is, "Oh, okay, there's a bump there."

0:39

The pituitary stalk is thickened or enlarged.

0:42

You really have to go more posterior to look at the stalk.

0:45

You're still in the tuberalis right here,

0:47

and now you're in the stalk.

0:48

It's more linear.

0:49

And I'd like to talk about that anatomy right

0:52

in profile in the stalk, in the sagittal projection.

0:55

So let's talk about things like deviation and tilt and

0:58

tapering and maybe even tumors that occur around the stalk.

1:01

Right.

1:01

Well, you know, we tend to focus on the gland,

1:04

but there are processes that can affect primarily the stalk.

1:08

Okay? Such as Lymphocytic Hypophysitis,

1:12

Eosinophilic granuloma,

1:13

and there's some tumors there, pituicytoma.

1:16

So the question is,

1:18

is this stalk normal or is it one of those things?

1:21

Okay, so how do we make that distinction?

1:23

Well, first of all thing you're going to be looking

1:25

at for first is deviation of the stalk.

1:28

But, you know, that can be a pretty common physiologic finding.

1:32

Sure. So when you say deviation, you mean to one side.

1:34

Yeah, it's a little bit tilted in this view.

1:36

Let me take this from you and just get you back in swing here.

1:40

So it's a little bit tilted in this view.

1:41

So the question is, "Well, is that a problem?"

1:45

Well, try to correlate with other things.

1:47

Dr. Pomeranz measured the tuft.

1:49

So if there's something pushing it,

1:51

we should probably see some other evidence of mass effect.

1:53

In the gland you mean?

1:55

In the gland, correct.

1:55

So is it being pushed?

1:57

There's nothing in the suprasellar space pushing it.

1:59

The other thing is enhancement of the stalk is a

2:05

normal finding, even avid enhancement.

2:07

Sure.

2:07

Okay.

2:08

But I think one of the main things that we can use is the

2:12

stalk should be tapered. Okay?

2:14

Wider at the top, coming down.

2:16

So these things that we talked about,

2:19

lymphocytic, hypophysitis, EG,

2:20

they're going to give you a nodular bumpy stalk and it's

2:24

not going to preserve that taper from top to bottom.

2:27

Okay. You're going to see it widened.

2:29

So it's wider up top and irregular.

2:31

It should be triangular and linear as you come down.

2:34

Right. I think you could see that here.

2:35

So the configuration is going to help you more than

2:37

the enhancement because the enhancement is normal.

2:40

And are there other things elsewhere that

2:43

suggest something's going on. Okay?

2:45

So I would say that this stalk is probably physiologic

2:48

avidly enhancing but with preservation of that taper.

2:52

So the bottom line is it's going

2:54

to be chubbier at the top.

2:55

It's going to taper as you come down in both projections.

2:58

It's tapering this way

2:59

and it's also tapering this way.

3:01

It's not nodular.

3:03

We allow for some deviation to one side or the other.

3:07

We allow for some tilting in either direction.

3:10

Those don't bother us as long as no other

3:13

ancillary findings are present.

3:15

And you certainly don't want to overcall a pituitary

3:17

abnormality based on those individual variations and

3:20

criteria we described. Let's move on, shall we?