Answer for BIR CoW 18 June 2023
Pituitary macroadenoma with Apoplexy
Findings
Evidence of T1 Hypointense / T2 /FLAIR hyperintense thick walled cystic lesion noted occupying sellar and suprasellar region showing fluid filled levels and causing expansion of sella turica , dorsum sella, planum sphenoidale and cranial aspect of clivus showing peripheral rim of diffusion restriction with low ADC values and peripheral rim of gradient blooming . Pituitary not separately visualised. Multiple T2 /FLAIR hyperintensity showing diffusion restriction with low ADC values noted in bilateral centrum semiovale,corona radiata, right inferior frontal gyrus. . The lesion causes lateral displacement of cavernous segment of right Internal carotid artery. On contrast administration,peripheral thick rim of enhancement is seen. MRA reveals total occlusion of left internal carotid artery with attenuated flow in left middle cerebral artery. Attenuated flow noted in cavernous, clinoid and supraclinoid segments of right internal carotid artery with reformation of right middle cerebral artery.
Impression:
Pituitary macroadenoma with apoplexy and with acute infarcts in watershed areas due to total occlusion of left internal carotid artery with attenuated flow in left middle cerebral artery and right internal carotid artery
Differentials:
The differential is broadly that of a pituitary region mass with intrinsic high T1 signal. Necrotic pituitary macroadenoma -appearances are the same, but patients do not present acutely Adamantinomatous craniopharyngioma -calcification in 90% -usually in children -usually not acute presentation Rathke cleft cyst -usually asymptomatic -no associated mass -spherical Dermoid/teratoma -usually have a fat component -if ruptured, locules of fat density/intensity material are often seen in the subarachnoid space.
Discussion:
Pituitary apoplexy is a severe and potentially fatal medical condition characterised by the variable association of headache, vomiting, visual impairment, ophthalmoplegia, altered mental state and panhypopituitarism. The syndrome is often related to hemorrhagic infarction of the pituitary gland, usually in a condition of a pre-existing macroadenoma occurring in 1.6 to 2.8 % of patients with this neoplasm. In fact, huge hemorrhages can be a common finding in patients with macroadenomas without PA symptoms. The most common symptom is headache, with an incidence of 90–97 % ; the second most frequent symptom is the visual deficit, ranging from 50 to 82 % of cases , followed by nausea, vomiting, ocular palsy and meningism Many known factors predispose patients to symptomatic infarction of the pituitary, amongst which the most important are hypertension , diabetes mellitus , pituitary function dynamic tests , administration of anticoagulants, bromocriptine, oestrogens and radiotherapy. MRI performed during the acute phase of the clinical syndrome shows areas of hyperintensity on T1W1. After IV gadolinium administration, a slight and inhomogeneous contrast enhancement is evident . T2WI showed areas of mixed high and low signal intensity, with the presence of a possible thin peripheral ring of marked hypointensity, representing haemosiderin and ferritin deposition. T2WIs are even useful in the evaluation of potential compressions of the optic chiasm and hypothalamus by the tumour The possibility of a fluid debris level within the mass has been described by many authors. The upper fluid (hyperintense on T1W1) contains free extracellular meta-Hb and the lower layer (iso-hypointense on T1WI) corresponds to a sediment of red blood remnants. This finding is suggestive of late subacute haemorrhage and is considered a specific sign of pituitary apoplexy. T2*-weighted images are highly sensitive to the paramagnetic effects of deoxy-HB and meta-HB and show bleeding products and haemosiderin deposits as areas of strongly hypointense signal. The pre-existing adenoma on radiological follow-up might grow after bleeding and eventually re-bleed .In those patients treated conservatively, tumour growth after bleeding occurs within a wide range, as shown by different studies (from 6 to 90 %), but this indicates the need for clinical radiological follow-up 3–6 months after pituitary apoplexy and every year for at least 5 years.
References:
1. Brougham M, Heusner AP, Adams RD. Acute degenerative changes in adenomas of the pituitary body—with special reference to pituitary apoplexy. J Neurosurg. 1950;7:421–439. doi: 10.3171/jns.1950.7.5.0421. [PubMed] [CrossRef] [Google Scholar] 2. Wakai S, Fukushima T, Teramoto A, Sano K. Pituitary apoplexy: its incidence and clinical significance. J Neurosurg. 1981;55:187–193. doi: 10.3171/jns.1981.55.2.0187. [PubMed] [CrossRef] [Google Scholar] 3. Cardoso ER, Peterson EW. Pituitary apoplexy: a review. Neurosurgery. 1984;14:363–373. doi: 10.1227/00006123-198403000-00021
Findings
Evidence of T1 Hypointense / T2 /FLAIR hyperintense thick walled cystic lesion noted occupying sellar and suprasellar region showing fluid filled levels and causing expansion of sella turica , dorsum sella, planum sphenoidale and cranial aspect of clivus showing peripheral rim of diffusion restriction with low ADC values and peripheral rim of gradient blooming . Pituitary not separately visualised. Multiple T2 /FLAIR hyperintensity showing diffusion restriction with low ADC values noted in bilateral centrum semiovale,corona radiata, right inferior frontal gyrus. . The lesion causes lateral displacement of cavernous segment of right Internal carotid artery. On contrast administration,peripheral thick rim of enhancement is seen. MRA reveals total occlusion of left internal carotid artery with attenuated flow in left middle cerebral artery. Attenuated flow noted in cavernous, clinoid and supraclinoid segments of right internal carotid artery with reformation of right middle cerebral artery.
Impression:
Pituitary macroadenoma with apoplexy and with acute infarcts in watershed areas due to total occlusion of left internal carotid artery with attenuated flow in left middle cerebral artery and right internal carotid artery
Differentials:
The differential is broadly that of a pituitary region mass with intrinsic high T1 signal. Necrotic pituitary macroadenoma -appearances are the same, but patients do not present acutely Adamantinomatous craniopharyngioma -calcification in 90% -usually in children -usually not acute presentation Rathke cleft cyst -usually asymptomatic -no associated mass -spherical Dermoid/teratoma -usually have a fat component -if ruptured, locules of fat density/intensity material are often seen in the subarachnoid space.
Discussion:
Pituitary apoplexy is a severe and potentially fatal medical condition characterised by the variable association of headache, vomiting, visual impairment, ophthalmoplegia, altered mental state and panhypopituitarism. The syndrome is often related to hemorrhagic infarction of the pituitary gland, usually in a condition of a pre-existing macroadenoma occurring in 1.6 to 2.8 % of patients with this neoplasm. In fact, huge hemorrhages can be a common finding in patients with macroadenomas without PA symptoms. The most common symptom is headache, with an incidence of 90–97 % ; the second most frequent symptom is the visual deficit, ranging from 50 to 82 % of cases , followed by nausea, vomiting, ocular palsy and meningism Many known factors predispose patients to symptomatic infarction of the pituitary, amongst which the most important are hypertension , diabetes mellitus , pituitary function dynamic tests , administration of anticoagulants, bromocriptine, oestrogens and radiotherapy. MRI performed during the acute phase of the clinical syndrome shows areas of hyperintensity on T1W1. After IV gadolinium administration, a slight and inhomogeneous contrast enhancement is evident . T2WI showed areas of mixed high and low signal intensity, with the presence of a possible thin peripheral ring of marked hypointensity, representing haemosiderin and ferritin deposition. T2WIs are even useful in the evaluation of potential compressions of the optic chiasm and hypothalamus by the tumour The possibility of a fluid debris level within the mass has been described by many authors. The upper fluid (hyperintense on T1W1) contains free extracellular meta-Hb and the lower layer (iso-hypointense on T1WI) corresponds to a sediment of red blood remnants. This finding is suggestive of late subacute haemorrhage and is considered a specific sign of pituitary apoplexy. T2*-weighted images are highly sensitive to the paramagnetic effects of deoxy-HB and meta-HB and show bleeding products and haemosiderin deposits as areas of strongly hypointense signal. The pre-existing adenoma on radiological follow-up might grow after bleeding and eventually re-bleed .In those patients treated conservatively, tumour growth after bleeding occurs within a wide range, as shown by different studies (from 6 to 90 %), but this indicates the need for clinical radiological follow-up 3–6 months after pituitary apoplexy and every year for at least 5 years.
References:
1. Brougham M, Heusner AP, Adams RD. Acute degenerative changes in adenomas of the pituitary body—with special reference to pituitary apoplexy. J Neurosurg. 1950;7:421–439. doi: 10.3171/jns.1950.7.5.0421. [PubMed] [CrossRef] [Google Scholar] 2. Wakai S, Fukushima T, Teramoto A, Sano K. Pituitary apoplexy: its incidence and clinical significance. J Neurosurg. 1981;55:187–193. doi: 10.3171/jns.1981.55.2.0187. [PubMed] [CrossRef] [Google Scholar] 3. Cardoso ER, Peterson EW. Pituitary apoplexy: a review. Neurosurgery. 1984;14:363–373. doi: 10.1227/00006123-198403000-00021
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!