Pituitary apoplexy

There is a large soft tissue lesion centered on the sella with associated bony destruction. Inferiorly the lesion expands the sphenoid sinus with destruction of the clivus posteriorly. There is extension into the cavernous sinuses bilaterally which are expanded. The posterior-most aspect of the ethmoidal air cell are also involved.

A more hypodense cystic-appearing component is located posteriorly and superiorly with associated mass effect on the left side of the brainstem, on the third ventricle and basal ganglia.

Conclusion

Large sellar and suprasellar mass is likely a pituitary macroadenoma. Further assessment with MRI is recommended.

There is a large heterogeneously T2 hyperintense mass with enhancement centered on the pituitary fossa with marked suprasellar extension and a dorsally angulated superior mixed solid cystic component interposed between the mesial temporal lobe, interpeduncular cistern and left cerebral peduncle. A fluid-fluid level is demonstrated in the dominant cystic component superiorly, with low T2 signal inferiorly, likely reflecting blood product. There is cavernous sinus invasion on both sides with no narrowing of the encased internal carotid arteries.

Marked invasion into the sphenoid bone to the level of the pterygoid plates. Almost the entire clivus is replaced with tumor and the posteroinferior extent is into the anterior occipital condyles bilaterally. The orbital apex is surrounded on both sides by tumor, with invasion into the posterior ethmoid air cells.

The optic nerves are traceable back to the optic chiasm, which is medial to the superior cystic component. The left optic tract is difficult to identify with confidence. This may be medial but could be stretched over the top of the cyst.

The left PCOM is displaced superiorly and draped over the top of the cyst. The left A1 and proximal M1 are mildly displaced anteriorly. Significant mass effect on the mesial temporal lobe, left cerebral peduncle, without obvious parenchymal edema on the sequences obtained. The third ventricle is partially compressed and displaced to the right with partial effacement of the left foramen of Monroe. No hydrocephalus at this stage. The remainder of the brain is unremarkable.

Conclusion

The large heterogeneous enhancing mass centered on the pituitary fossa is consistent with a pituitary macroadenoma. In this clinical context, hemorrhage into the superior cystic component is in keeping with pituitary apoplexy.