Presentation
Acute onset of "worst" headache and blurred vision.
Patient Data
A well-defined hyperdense sellar mass with suprasellar component. The attenuation of the mass measures 50-60HU, which may represent blood clot. No calcification or fat component seen within this mass. There is widening and bone remodeling of the sella turcica/pituitary fossa, indicating a slow growing tumor. Superiorly, the optic chiasm is compressed, worst on the right side.
From plain CT brain, the working diagnoses are either pituitary apoplexy or thrombosed aneurysm at circle of Willis.
Proceeded with MRI brain.
A lobulated mass with epicenter at the sella turcica. Presence of area of hyperintense signal on T1W and hypointese signal on T2W at its dependent part suggestive of subacute blood component. The mass show diffuse blooming artifact in gradient echo suggestive of hemorrhagic component. Heterogenous enhancement seen predominantly at its periphery.
Annotated image shows the enlarged pituitary mass with suprasellar extension resulting in compression onto optic chiasm.
Case Discussion
Pituitary apoplexy is an acute clinical syndrome caused by either hemorrhage or infarction of the pituitary gland. For clinical presentation, it typically comprises of severe headache, visual deficits, ophthalmoplegia, and altered mental status.
The most important differential diagnosis to consider for a hyperdense suprasellar/sellar mass is aneurysm.
In this case, MRI imaging features that are against the diagnosis of aneurysm:
Absence of low signal intensity/ black signal on T1-weighted images to suggest flow void/rapid blood flow.
No extension of this mass into either cavernous sinuses.
No communication with the adjacent circle of Willis.
No pulsating artefacts on MRI images
No significant internal enhancement post contrast.
Unable to process the form. Check for errors and try again.