Description

Intra tumoral haemorrhage occurs frequently in pituitary macro adenomas. It can either manifest as pituitary apoplexy [1], a life threatening condition with sudden onset of headaches, nausea and vomiting; or as a silent recent or old haemorrhage. In the latter, like in our case, MR imaging is best to delineate these haemorrhagic changes. In fact, typical features are T1 and T2 hyperintensity (Figure 1A & 1B), persisting in fat saturated sequences (Figure 1C) with peripheral enhancement (Figure 1D). Usually a subsequent cystic change occurs, responsible for a fluid-fluid level (Figure 1E). Among the differential diagnosis of supra sellar masses, cystic craniopharyngiomas typically have calcifications although better appreciated on CT and a vividly enhancing solid component. Arachnoid cysts are very thin walled cystic supra sellar lesions with no solid or enhancing component, usually extending superiorly to the third ventricle and can be causing obstructive hydrocephalus. Rathke cleft cyst remains the most challenging differential, recent efforts were made to help make the correct diagnosis [2]. In that matter the classic appearance of a midline sellar and supra sellar lesion with fluid-fluid level, haemorrhagic changes and a T2 hypointense rim (Figure 1E) clinches the diagnosis of a haemorrhagic pituitary macroadenoma.

Disclaimers or conflict of interest: None.

Figure 1:

References

1. Mayol Del Valle M, De Jesus O. Pituitary Apoplexy. 2023 Aug 8. In: Stat Pearls. Treasure Island (FL): StatPearls Publishing. 2023.
2. Park M, Lee SK, Choi J, Kim SH, Kim SH, et al. Differentiation between Cystic Pituitary Adenomas and Rathke Cleft Cysts: A Diagnostic Model Using MRI. AJNR Am J Neuroradiol. 2015; 36: 1866-73.