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title: "Enlarged Pituitary Gland"
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docid: "65e54fd1-aecf-463c-bd85-97504c542051"
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authors:
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- key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
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value: "Karen L. Salzman, MD, FACR"
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- key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
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value: "Anne G. Osborn, MD, FACR"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
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-
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name: "Sella/Juxtasellar, Pineal Region"
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slug: "sellajuxtasellar-pineal-region"
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treeNodeId: "5e38b9c1-3137-47e3-aa83-1fc82cb4099a"
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-
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name: "Anatomically Based Differentials"
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slug: "anatomically-based-differentials"
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treeNodeId: "7a51b2ca-8fee-4c16-aff3-b7189f68ea60"
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-
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name: "Enlarged Pituitary Gland"
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slug: "enlarged-pituitary-gland"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "6624d150-d588-4aed-b1dd-621505522f70"
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imageCount: 23
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lastUpdated: "01/27/23"
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pageDescription: "Enlarged Pituitary Gland"
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pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Enlarged Pituitary Gland"
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pageTitle: "Enlarged Pituitary Gland | STATdx"
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enhancedTitle: "Enlarged Pituitary Gland"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Differential Diagnosis"
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- "Sella/Juxtasellar, Pineal Region"
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- "Anatomically Based Differentials"
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- "Enlarged Pituitary Gland"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Not all "enlarged pituitary glands" abnormal
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- Size/height varies with sex, age
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- Children: 6 mm
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- Males, postmenopausal females: 8 mm
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- Young, menstruating females: 10-12 mm (can bulge upward)
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- Pregnant, postpartum, lactating females: 12-14 mm
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- Enhances strongly, uniformly
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- 15-20% have incidental cyst or nonfunctioning microadenoma (pituitary "incidentaloma")
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- Variants/mimics of "enlarged pituitary"
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- Pseudoenlargement secondary to unusually shallow bony sella or "kissing carotids"
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- Medially positioned cavernous internal carotid arteries ("kissing carotids") may make gland appear enlarged
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- ## Helpful Clues for Common Diagnoses
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- **Pituitary****H****yperplasia**
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- Can be normal (young, menstruating females)
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- Enlarged gland ± upward bulging
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- May be related to end-organ failure (i.e., hypothyroidism, ovarian) or neuroendocrine tumors
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- **Pituitary****M****icroadenoma**
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- May enlarge gland
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- Best identified with dynamic, contrast-enhanced MR
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- **Pituitary****M****acroadenoma**
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- Pituitary gland cannot be distinguished from mass
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- Enhances strongly, often heterogeneously
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- Typically sellar and suprasellar mass
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- ## Helpful Clues for Less Common Diagnoses
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- **Lymphocytic Hypophysitis**
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- May enlarge pituitary gland, ± infundibulum
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- May mimic macroadenoma
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- Common in pregnant and postpartum females
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- Different types: Autoimmune, granulomatous, IgG4 related, drug related (i.e., ipilimumab)
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- **Neurosarcoid**
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- Affects hypothalamic-pituitary axis in 50%
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- Diffusely enhancing lesion involving stalk ± gland
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- **Langerhans Cell Histiocytosis**
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- Loss of posterior pituitary bright spot
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- Enhancing infundibulum ± gland, hypothalamus
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- Young patients
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- ## Other Essential Information
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- Venous congestion (intracranial hypotension, dural arteriovenous fistula) can enlarge gland
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- Caution: Child or young adolescent male with "pituitary adenoma" most likely has pituitary hyperplasia; less likely LCH or germinoma, **not** adenoma
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- Evaluate for end-organ failure (e.g., hypothyroidism)
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- In **child/young adult**, consider pituitary hyperplasia, LCH, lymphocytic hypophysitis, anatomic variants
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- In **adult**, consider pituitary adenoma, hyperplasia, hypophysitis, neurosarcoid, lymphoma, metastatic disease
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## References
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# Selected References
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1. [Bashari WA et al: Modern imaging in Cushing's disease. Pituitary. 25(5):709-12, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35666391%5Bpmid%5D)
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1. [Chalif EJ et al: Pituitary adenoma in the elderly: surgical outcomes and treatment trends in the United States. J Neurosurg. 1-12, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35535847%5Bpmid%5D)
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1. [Potorac I et al: Pituitary MRI features in acromegaly resulting from ectopic ghrh secretion from a neuroendocrine tumor: analysis of 30 cases. J Clin Endocrinol Metab. 107(8):e3313-20, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35512251%5Bpmid%5D)
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1. [Villemaire A et al: Is systematic gadolinium injection relevant during MRI follow-up for non-functioning pituitary macroadenomas? J Neuroradiol. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36055429%5Bpmid%5D)
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1. [Altshuler DB et al: Imaging errors in distinguishing pituitary adenomas from other sellar lesions. J Neuroophthalmol. 41(4):512-18, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33630780%5Bpmid%5D)
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1. [Huang J et al: Noncontrast MRI protocol for selected pediatric pituitary endocrinopathies: a procedure with high diagnostic yield and potential to reduce anesthesia and gadolinium-based contrast exposure. AJNR Am J Neuroradiol. 42(10):1884-90, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34475192%5Bpmid%5D)
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1. [Mittal PK et al: Role of imaging in the evaluation of male infertility. Radiographics. 160125, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28410062%5Bpmid%5D)
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1. [Zamora C et al: Sellar and parasellar imaging. Neurosurgery. 80(1):17-38, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28362892%5Bpmid%5D)
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1. [Kocova M et al: Diagnostic approach in children with unusual symptoms of acquired hypothyroidism. When to look for pituitary hyperplasia? J Pediatr Endocrinol Metab. 29(3):297-303, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26587741%5Bpmid%5D)
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1. [Fujita A et al: IgG4-related disease of the head and neck: CT and MR imaging manifestations. Radiographics. 32(7):1945-58, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=23150850%5Bpmid%5D)
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## Images
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### Selected Images
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**Pituitary Hyperplasia**
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*Sagittal T1 MR in a teenager with hypothyroidism shows marked enlargement of the pituitary gland <img src='img/arrows/CS.png'/> related to pituitary hyperplasia. The pituitary gland returned to normal size after the hypothyroidism was treated.*
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**Pituitary Hyperplasia**
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*Sagittal T1 MR in a teenager with hypothyroidism shows marked enlargement of the pituitary gland <img src='img/arrows/CS.png'/> related to pituitary hyperplasia. The pituitary gland returned to normal size after the hypothyroidism was treated.*
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**Pituitary Microadenoma**
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*Coronal T1 C+ FS MR in a 55-year-old woman shows a mildly enlarged right pituitary gland <img src='img/arrows/CO.png'/> related to a prolactin secreting microadenoma. Microadenomas are benign tumors of the adenohypophysis that are often seen best on dynamic contrast MR.*
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**Pituitary Macroadenoma**
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*Coronal T1 C+ MR shows an enlarged pituitary gland <img src='img/arrows/CS.png'/> related to a macroadenoma. Note displacement of the pituitary infundibulum <img src='img/arrows/WS.png'/> to the contralateral side, typical of adenomas.*
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**Lymphocytic Hypophysitis**
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*Sagittal T1 C+ FS MR shows marked enlargement of the pituitary gland <img src='img/arrows/CS.png'/> and infundibular stalk <img src='img/arrows/CO.png'/> in this patient being treated with Ipilimumab for metastatic melanoma. The drug-related hypophysitis resolved after the therapy was discontinued.*
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**Neurosarcoid**
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*Sagittal T1 C+ MR shows a diffusely enlarged, enhancing pituitary gland <img src='img/arrows/CO.png'/> in a young female with pituitary dysfunction. Neurosarcoid was diagnosed at resection. Imaging mimics the much more common pituitary adenoma.*
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**Langerhans Cell Histiocytosis**
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*Sagittal T1 C+ MR shows a uniformly enlarged, enhancing pituitary gland <img src='img/arrows/CO.png'/> in this young adult with known Langerhans cell histiocytosis (LCH). LCH often presents with diabetes insipidus and loss of the normal posterior pituitary bright spot.*
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**Lymphoma, Primary CNS**
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*Coronal T2 MR shows enlargement of the pituitary gland by a mass <img src='img/arrows/CS.png'/> with extension to the left cavernous sinus <img src='img/arrows/CO.png'/>. Lymphoma is often infiltrative, DWI positive, and diffusely enhances. Pituitary involvement is rare.*
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**Intracranial Hypotension**
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*Sagittal T1 MR shows a sagging midbrain <img src='img/arrows/WC.png'/> with a decreased mamillopontine distance and a prominent pituitary gland <img src='img/arrows/CO.png'/>. The optic chiasm is draped over the gland <img src='img/arrows/WS.png'/> in this patient with intractable headaches. Diffuse dural enhancement is common in intracranial hypotension.*
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### Additional Images
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**Intracranial Hypotension**
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*Sagittal T1 MR shows a sagging midbrain <img src='img/arrows/WC.png'/> and a prominent pituitary gland <img src='img/arrows/CO.png'/>. The optic chiasm is draped over the gland <img src='img/arrows/WS.png'/> in this patient with postural hypotension and intractable headaches. Inferiorly displaced tonsils are common in intracranial hypotension.*
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**Anatomic Variants (Small Sella Turcica, "Kissing Carotids")**
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*Sagittal T1 MR shows a very shallow bony sella <img src='img/arrows/WO.png'/> with the optic chiasm <img src='img/arrows/WS.png'/> draped over the pituitary gland. The gland measures 9 mm, which is normal in 19-year-old women. Although the gland appears enlarged, it is actually a pseudoenlarged gland.*
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**Neurosarcoid**
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*Sagittal T1 MR shows a diffusely enlarged pituitary gland <img src='img/arrows/CO.png'/> in a young female with pituitary dysfunction. Neurosarcoid was diagnosed at resection. Imaging mimics the much more common pituitary adenoma.*
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**Pituitary Macroadenoma**
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*Coronal T1 C+ MR shows an enlarged pituitary gland <img src='img/arrows/CS.png'/> with a heterogeneous macroadenoma. Pituitary apoplexy can be considered in patients with acute clinical features, including headache, visual defects &/or altered mental status, and a heterogeneous pituitary mass.*
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**Neurosarcoid**
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*Coronal T1 C+ MR shows a diffusely enlarged, enhancing pituitary gland <img src='img/arrows/CO.png'/> in a 32-year-old female patient with pituitary dysfunction. Neurosarcoid was diagnosed at resection. Imaging mimics the much more common pituitary adenoma.*
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**Langerhans Cell Histiocytosis**
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*Coronal T1 C+ MR shows a uniformly enlarged, enhancing pituitary gland <img src='img/arrows/CO.png'/> with upward displacement of the optic chiasm <img src='img/arrows/WS.png'/> in this child with known LCH. LCH often presents with diabetes insipidus and loss of the normal posterior pituitary bright spot.*
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**Pituitary Microadenoma**
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*Sagittal T1 C+ FS MR in a 53-year-old man shows a mildly enlarged pituitary gland with a focal area of less enhancement <img src='img/arrows/CO.png'/> related to a microadenoma. Microadenomas are benign tumors of the adenohypophysis that are often seen best on dynamic CEMR.*
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**Pituitary Macroadenoma**
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*Sagittal T1 MR shows an enlarged pituitary gland <img src='img/arrows/WS.png'/> that elevates the optic chiasm <img src='img/arrows/WO.png'/>. This enlarged gland is almost isointense with the brain in this example of classic macroadenoma.*
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**Metastases to Gland/Stalk**
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*Sagittal T1 C+ MR shows thickened, enhancing infundibulum <img src='img/arrows/WS.png'/> and a slightly enlarged pituitary gland <img src='img/arrows/BO.png'/> in a patient with known metastatic disease.*
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**Metastases to Gland/Stalk**
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*Coronal T1 C+ MR shows an enhancing suprasellar mass <img src='img/arrows/WS.png'/> in a patient with known metastatic lung cancer and diabetes insipidus.*
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**Pituicytoma**
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*Coronal T1 MR shows an enlarged pituitary gland <img src='img/arrows/WO.png'/> with hyperintense focus <img src='img/arrows/WS.png'/>. Preoperative diagnosis was Rathke cleft cyst. Granular cell tumor (type of pituicytoma) was found at surgery.*
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**Pseudotumor, Intracranial**
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*Coronal T1 C+ MR shows an enlarged pituitary gland <img src='img/arrows/BC.png'/> and stalk <img src='img/arrows/WS.png'/>. Note dural thickening <img src='img/arrows/WO.png'/>. Scan was normal after intravenous steroid administration.*
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**Lymphoma, Primary CNS**
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*Coronal T1 C+ MR shows a mass diffusely infiltrating the pituitary gland <img src='img/arrows/WS.png'/>. Extension into the cavernous sinus <img src='img/arrows/BO.png'/> helps identify more aggressive pathology.*
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**Pituitary Hyperplasia**
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*Coronal T1 C+ MR shows a physiologically enlarged pituitary gland <img src='img/arrows/WS.png'/> in this 28-year-old lactating woman. The gland measures nearly 12 mm in height. Follow-up scan 1 year later was normal.*
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**Pituitary Microadenoma**
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*Coronal T1 C+ MR in a 51-year-old man shows a mildly enlarged pituitary gland <img src='img/arrows/WS.png'/> measuring 11 mm in height. Note the faint area of slightly less enhancement <img src='img/arrows/BO.png'/>. An 8-mm microadenoma was found at surgery.*
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