0:00

Dr. Shupek,

0:01

let's look at this 30-year-old infertility patient.

0:04

And I'd ask you the question again,

0:05

as I did in a prior vignette.

0:06

Is this case tough or just simply tough?

0:10

Yeah, well,

0:11

we are all becoming together aficionados of the tuft.

0:16

And I kind of picked out this case because it

0:20

kind of shows the utility of that finding.

0:22

Okay, so this is a patient, a young patient,

0:25

hyperprolactinemia and infertility. Okay?

0:30

So if you look in the Sagittal view, Dr.

0:32

Pomerance went over the Sagittal how to use that,

0:35

the post-contrast images is this tiny little

0:38

dot there. Okay? So the question is,

0:43

is there action there or we're kind

0:45

of just imagining stuff? Well,

0:48

this is a way that you can use the pituitary tuft,

0:51

okay? Because here we are, here's the pituitary tuft,

0:54

and here's this lesion,

0:56

and there's a little bit of mass effect on the tuft.

0:58

I would say it's a little bowed from right to left.

1:01

So we're going to have to take this thing kind of

1:03

seriously as being a possible

1:05

lesion because it's exerting

1:09

a mass effect. Now, the stalk is not deviated,

1:13

but it's so small,

1:14

it's in the inferior portion of the gland,

1:16

but it's in the anterior portion.

1:18

It's in front of the pars intermedia, probably.

1:20

So it's in part of the gland where

1:22

we might expect an adenoma.

1:24

Okay,

1:24

so this is one way that you can use the tuft.

1:27

Now, another thing that is very important if you can get

1:31

this information is what's the prolactin level?

1:34

Okay,

1:35

because prolactin levels can go up

1:37

for a lot of different reasons.

1:39

2025 phenothiazines

1:43

verapamil, I think,

1:44

will do a number of other medications,

1:47

a number of other physiologic states.

1:49

But when you get a prolactin 100 or above,

1:52

your chances of it being an adenoma,

1:57

Yeah, really high. And above 150, it's like 99.9%.

2:02

You can get compression of the gland extrinsically

2:04

that causes prolactin secretion,

2:06

but almost never above 100 or 150.

2:09

So if you got an infertility patient,

2:11

your prolactin level is 130.

2:13

You almost have to have a microadenoma.

2:15

So that's going to push you towards being more

2:17

aggressive with these tiny little dots.

2:19

And as Dr. Shupeck said,

2:21

this time we have a pituitary tuft and a tough little

2:26

nasty microadenoma that is producing infertility.

2:29

Let's move on, shall we?