Pituitary macroadenoma

Case contributed by Dr Mohamed Mahmoud Elthokapy

Presentation

Chronic headache, diminution of vision and bi-temporal hemianopia on ophthalmological examination.

Patient Data

Age: 55 years
Gender: Male

Brain and sella

MRI

Evidence of a sizable sellar and supra-sellar mass lesion. It is iso to hypointense on T1WI and iso- to hyperintense on T2WI and FLAIR. It shows heterogenous enhancement with small cystic non-enhanced components.

Extensions and mass effect:

  • laterally, it is partially encasing both internal carotid arteries at the cavernous sinus bilaterally, yet still patent judged by signal void denoting their patency 
  • inferiorly, expanding the sellar cavity and its floor compressing both sphenoid sinuses with no intra-sinus extensions
  • superiorly, it is markedly compressing the optic chiasm and both optic tracts, additionally noted it is indented by the diaphragma sellae giving it a snowman configuration (or "figure 8" or "dumbbell" configuration) as at coronal image.

Multiple bilateral periventricular white matter patches and foci of altered signal intensities eliciting bright T2 and FLAIR signal suggesting small artery disease (Fazekas type II)

Cavum septum pellucidum is incidentally noted.

Case Discussion

Pituitary macroadenomas are the most common suprasellar mass in adults, and responsible for the majority of trans-sphenoidal hypophysectomy.

On imaging, they usually present as a solid tumor and demonstrates moderate contrast enhancement. They are isointense to the grey matter both on T1 and T2-weighted images. However, signal characteristics can significantly vary depending on tumor components such as hemorrhage, cystic transformation or necrosis.

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