Unusual masses in the region of the pituitary

From Lewis S Blevins Jr, MD  –  Whenever we see unusual masses in the region of the pituitary we often think or ask ourselves: Could this be a blood vessel abnormality? Could this be an aneurysm?

Carotid-cavernous fistula is an abnormal connection between the carotid artery and a vein in the cavernous sinus. It can present as an enlarging mass in the pituitary gland. It has the characteristic radiographic appearance of a flow void similar to that seen in the carotid artery, often thickening of the luminal wall of the vessel, and dilated veins. Sometimes they’re thought to represent degenerative pituitary adenomas but it’s usually evident that they are not an adenoma based on the radiographic characteristics. I am often surprised, however, that radiologist do not entertain the diagnosis of aneurysm or fistula despite characteristic findings. They are usually associated with an oculomotor nerve palsy on the affected side leading to double vision and a droopy eyelid on that particular side. Both eyes may develop a characteristic redness and swelling of the membranes called chemosis. Bruits, an abnormal repeated group of sounds indicating blood flow, are usually heard on the temple on the affected side. Pituitary functions are usually normal but can be abnormal in patients with rather large lesions. Patients can be managed in a number of different ways depending on the actual blood flow characteristics, the presence of collateral circulation, etc.

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