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Pituitary Macroadenoma

Case Detail

Anatomy: Brain-Spine
Junewick
Joseph Junewick, MD FACR
Diagnostic Category: Neoplasia Benign
Created: over 6 years ago
Updated: over 6 years ago
Tags: PEDS
Modality/Study Types: MR CT
Activities:
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History

12 year old female with headache and visual disturbance.


Case Images


Diagnosis

Pituitary Macroadenoma

Clinical Notes

Markedly elevated growth hormone and insulin-like growth factors

Findings

CT – Multilobulated hyperdense mass with fluid-fluid levels and enhancement. Note the expanded sella tursica.

MR – Large mass arising from the sella tursica with invasion of the right cavernous sinus. The layering T2 hypointensity indicates intralesional hemorrhage.

Discussion

Classical pituitary apoplexy is a clinical syndrome characterized by sudden onset of headache, vomiting, visual impairment, diplopia, disturbance of consciousness, and autonomic or hormonal dysfunction. Strict medical management and surgical decompression for endocrinologic and neurologic problems are usually required. Pituitary apoplexy is caused by acute hemorrhagic or ischemic infarction of the pituitary gland in patients harboring pituitary adenomas. Early in the course of pituitary apoplexy, MR imaging depicts a mass lesion as heterogeneous signal intensity with predominant hyperintensity on T1-weighted MR images and predominant hypointensity on T2-weighted images.

Accurate assessment of intratumoral hemorrhage in pituitary macroadenoma has increased in importance. Patients with pituitary macroadenomas can sometimes be followed up by MR imaging because of a relatively benign prognosis. Hemorrhage could cause tumoral enlargement and aggravate the patient’s symptoms. The presence of a hemorrhagic cavity often facilitates removal of a macroadenoma, and such information may be useful for surgical planning.

Only dura separates the sella tursica from the cavernous sinus; there are no lateral bone boundaries to the pituitary fossa. Consequently extension typically occurs in this direction. Approximately 10% of pituitary adenomas involve the cavernous sinus. Invasive disease has to be distinguished from lateral expansion without invasion. With expansion, the dura is intact whereas with invasion the dura is violated. The consequences of cavernous sinus invasion by pituitary adenoma are clinically important because they render the surgical procedure more difficult and less efficient. Invasion increases the frequency of intraoperative injury to the intracavernous ICA and of postoperative cerebrospinal fluid leakage. Dural wall invasion usually implies partial surgical removal of the tumor and requires additional therapy (ie, conventional radiation therapy, radiosurgery, or suppressive drugs).

Reference

Cottier JP, Destrieux C, Brunereau L, Bertand P, et al. Cavernous Sinus Invasion by Pituitary Adenoma: MR Imaging. Radiology (2000); 215:463-469.

Tosakaa M, Satob N, Hiratoc J, Fujimakia H, et al. Assessment of Hemorrhage in Pituitary Macroadenoma by T2*-Weighted Gradient-Echo MR Imaging. AJNR (2007); 28:2023–29.



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