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Diagnosis certain
Presentation
Patient Data
ACTH dependent Cushing's syndrome and congestive cardiac
failure. CT of the chest, abdomen and pelvis demonstrates no
focal abnormality.
AGE: 70 years
GENDER: Female
MRI pituitary
Sagittal T1
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Inferior petrosal sinus sampling
Case contributed by Assoc Prof Frank Gaillard ◉ ◈
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MRI
Sagittal T1 C+
Coronal T2
Coronal T1
Coronal T1 C+
Coronal
Dynamic
position 1
MRI
MRI
MRI
MRI
MRI
Scroll Stack
MRI
Sagittal T1
Two 3 millimeter areas of delayed enhancement are seen in the pituitary gland, one on the
right just posterior to the level of the stalk and the other more centrally at the same level.
Whether both of these are functional microadenomas or whether one is non secretory is
uncertain. Pituitary stalk is midline. Chiasm and cavernous sinuses are uninvolved, with
normal cavernous carotid !ow voids.
4 case questions available
Annotated images
ANNOTATED IMAGE
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Two possible microadenomas. One seen best on dynamic imaging (red arrow) is the more
likely one. On delayed coronals another apparent region of hypo-enhancement (blue arrow) is
seen, however as it neither seen on dynamic or sagittal imaging it is unlikely to be real.
Inferior petrosal sinus sampling
Lt jug bulb frontal
Lt jug bulb lateral
DSA (ANGIOGRAPHY)
Lt IPS - frontal
Lt IPS - lateral
Rt jug bulb frontal
Rt jug bulb lateral
DSA
DSA (angiography)
(angiography)
DSA
(angiography)
DSA
DSA
(angiography)
(angiography)
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DSA (angiography)
Lt jug bulb - frontal
Bilateral groin punctures were performed and 5 french catheters passed up the IVC, through
the right atrium and SVC into the internal jugulars to the base of skull. Injection of contrast
retrogradely opaci"ed the inferior petrosal sinuses which were entered with micro-catheters
placed equidistant from the pituitary fossa, their position con"rmed with further injections of
contrast.
Following this simultaneous sampling of each microcatheter and the peripheral venous blood
(via the groin sheath) was performed pre and post administration of CRH.
1 case question available
Annotated images
ANNOTATED IMAGE
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Frontal projection of injection into the left jugular demonstrating retrograde !ow up the left IPS and across to the
right IPS. Retrograde !ow up the sigmoid and transverse sinus and across to the right side is also noted.
.
2 case questions available
The venous ACTH levels obtained from the right and left petrosal sinuses and peripheral blood are as
follows (00:00 = baseline, other times are in minutes post CRH administration):
00:00 right perosal sinus
14.7
00:02 right perosal sinus
243
00:05 right perosal sinus
139
00:10 right perosal sinus
93.0
00:15 rigth perosal sinus
58.4
00:00 left perosal sinus
8.06
00:02 left perosal sinus
81.7
00:05 left perosal sinus
81.3
00:10 left perosal sinus
11.5
00:15 left perosal sinus
8.50
00:00 peripheral
1.40
00:02 peripheral
1.51
00:05 peripheral
1.43
00:10 peripheral
2.53
00:15 peripheral
3.29
These results are consistent with a pituitary microadenoma, most likely in the right side of the gland.
Case Discussion
On the basis of the IPSS and MRI this patient went on to have an exploratory transphenoidal
hypophysectomy. Although histological proof of a microadenoma was not achieved, the patient
became biochemically normal following surgery and their ACTH levels returned to normal.
At 18 months follow up remains well with normal pituitary function.
Case courtesy of A/Prof Peter Mitchell, Royal Melbourne Hospital
1 article features images from this case
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