Clinical question: 66-year-old male with HCC, left eye proptosis, CT head negative, concern for possible metastases. Signs and symptoms: Left eye ptosis, headache. Nonenhanced brain MRI:No acute intracranial process and negative diffusion weighted series.Examination demonstrate mild patchy foci of periventricular and subcortical low-attenuation white matter which although nonspecific this appearance is often is secondary to microvascular ischemic changes.There is a small mass within the left aspect of the pituitary gland and apparent extension laterally into the left cavernous sinus as well as deviation of the pituitary stalk to the right. There is no associated bony changes with this finding on current brain MRI exam or prior head CT exam. This appearance is highly suggestive of a pituitary adenoma with invasion of the left cavernous sinus. The finding measures approximately 11 x 11 mm on coronal T2 weighted series 901 image 14. Remote possibility of metastases can also be considered. Lack of intravenous contrast reduces more precise evaluation of the lesion. The basal cistern remains widely patent and the left cavernous sinus demonstrate no decrease caliber secondary to tumor on this nondedicated exam.The signal intensity and anatomical morphology of the brain is otherwise within normal limits and with normal signal intensity on all MRI sequences.Calvarium demonstrate normal signal intensity.Images through the orbits are unremarkable. All paranasal sinuses and bilateral mastoid air cells and middle ear cavities remain well pneumatized.
1.No acute intracranial process.2.Negative diffusion weighted images and findings suggestive of mild chronic small vessel ischemic strokes only in the subcortical and periventricular white matter.3.Small pituitary adenoma on the left with invasion of the left cavernous sinus and subtle deviation of pituitary stalk to the right as detailed.4.Unremarkable nonenhanced brain MRI otherwise.5.Postcontrast images are recommended for more precise assessment.