27. Readful! Pituitary MRI (an approach) with James King
Aug 7, 2023
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Neurosurgeon James King discusses the approach to pituitary MRI and the importance of thoroughness in reviewing the entire brain. They also touch on the challenges of detecting micro adenomas, the occurrence of bi-temporal hemianopia in pregnancy, and the concept of pre-fixed and post-fixed position of the optic chiasm. A case involving a supercella lesion with pituitary involvement is also explored.
Having a systematic approach is crucial in interpreting pituitary MRI, identifying key structures and using the appropriate imaging protocol.
Factors like tumor characteristics, involvement of surrounding structures, and preoperative imaging help determine the surgical approach for pituitary surgery.
Accurate interpretation of pituitary MRI findings and clear communication with surgeons are essential in guiding patient management and minimizing complications.
Deep dives
Importance of a systematic approach to pituitary MRI
Having a systematic approach to interpreting pituitary MRI is crucial in detecting subtle lesions. It requires clear understanding of the local anatomy and the variety of pathologies that occur in the region. Key structures to identify include the pituitary gland, optic nerves, chiasm, tracks, diaphragmacella, boundaries of the cavernous sinus, and the presence of dynamic enhancement. The imaging protocol should include T1 and T1 post-contrast images, dynamic contrast-enhanced coronal images, and T2-weighted sequences. It is important to accurately describe the findings to guide surgical decision-making.
Challenges and considerations in pituitary surgery
Pituitary surgery can present challenges depending on the tumor's characteristics and the region's involvement. Factors such as suprasella and diaphragmatic opening size, invasion into the cavernous sinuses or other structures like the clivus and orbit, and the location of the pituitary tissue and infundibulum in relation to the mass should be assessed. The presence of necrotic or cystic areas, vascular anomalies, and bone involvement should also be noted. Preoperative imaging plays a crucial role in identifying these factors and, if possible, determining the surgical approach.
Interpreting pituitary MRI findings and their clinical significance
Accurate interpretation of pituitary MRI findings is vital in guiding patient management and determining the need for surgery. Factors such as size, necrotic/cystic areas, invasion into neighboring structures, presence of abnormal vessels, bone involvement, and sinus disease need to be specifically commented upon in the radiology report. Additionally, communication between radiologists and surgeons is important in assessing the surgical corridor, preserving normal pituitary tissue, and minimizing complications like CSF leaks. Providing a clear diagnosis and conveying the degree of certainty on the findings is also valuable for clinicians and patients.
Assessment and Surgery for Pituitary Lesions
The podcast episode discusses the assessment and surgical approach for pituitary lesions. The speaker mentions performing vertical incisions in the gland to look for small lesions, although this approach is not always effective. They also emphasize the importance of assessing the optic nerves, chiasm, and tracks for visual symptoms. The relationship of the chiasm to the pituitary and the presence of compressive lesions, such as meningiomas, are crucial considerations. The podcast also touches on the importance of good quality imaging to determine the best approach for lesions in the paracellar and cavernous sinus regions. Additionally, the podcast emphasizes the need to review the entire brain for any unexpected findings.
Differentiating Pituitary Lesions and Helpful Signs
The episode explores the differentiation of pituitary lesions based on their overall pattern, location, morphology, and signal. The speaker mentions various patterns to consider, such as solid and enhancing pituitary region masses, mixed cystic and solid masses, and purely intrasellar or suprasellar masses. They also discuss specific signs that aid in narrowing the differential diagnosis, including dural tail for meningiomas, diaphragm sellar displacement, and compression of the carotid artery. The episode highlights the importance of considering rare diagnoses like metastases, meningiomas, and other non-adenomas, as their management differs from macro adenomas. The speaker also emphasizes the challenges in distinguishing residual tumor from post-operative changes in imaging reports, and the importance of thoughtful communication with patients regarding these findings.
It's radiology read to you! Frank reads our approach to pituitary MRI article to neurosurgeon and pituitary expert James King and tries to uncover exactly what the surgeon wants to know from our reports. Meanwhile, Frank recounts his recent run in with a snake that he certainly didn't hear coming.
