PITUITARY PARASELLAR LESIONS. Kim Learned, MD

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1 PITUITARY PARASELLAR LESIONS Kim Learned, MD

2 DIFFERENTIALS Pituitary Sella Clivus, Sphenoid Sinus Suprasellar Optic chiasm, Hypothalamus, Circle of Willis Parasellar Cavernous Sinus

3 Case 1 17 YEAR-OLD FEMALE BITEMPORAL SUPERIOR QUADRANTOPSIA Diffuse gland enlargement

4 Adenoma Rathke s cleft cyst Apoplexy SELLAR-PITUITARY PATHOLOGIES Pituitary Infectious/Inflammatory: lymphocytic hypophysitis, Sarcoid, Abscess Metastasis: 1-3% sellar mass (breast, lung, GI, typically involved stalk/hypothalamus)

5 PITUITARY ADENOMA Microadenoma < 10 mm Local mass effect Deviation of normal pituitary Stalk and Gland

6 PITUITARY ADENOMA Hemorrhagic Cystic changes Cavernous sinus Protrusion (ICA abutment < 180) Invasion (ICA abutment >270)

7 RATHKE S CLEFT CYST Intrasellar or Upper margin of gland anterior to stalk Variable CT and T1-T2 intensity: CSF Mucoid/Hemorrhage. No Ca+ Intracystic nodule on T2: 75% cholesterol/mucopolysaccharide-hemorrhage Imperceptible-thin enhancing wall

8 PITUITARY APOPLEXY Infarction pituitary Headache, visual symptoms to shock Post-partum Sheehan syndrome Adenoma acute bleed with expansion results in clinical symptoms Bromocriptine predisposes to tumor hemorrhage Pituitary hemorrhage on MRI Clinical Apoplexy

9 Case 1 LYMPHOCYTIC HYPOPHYSITIS Diffuse infiltration of the gland with convex contour, elevation-thickening of the stalk

10 DIFFUSE PITUITARY GLAND PROCESS Hyperplasia Macroadenoma Infiltrative processes lymphocytic hypophysitis, sarcoid, granulomatous disease

11 Case 3 INCIDENTAL FINDINGS A. Pituitary adenoma B. Sinonasal tumor C. Chordoma D. All above

12 Case 3 PITUITARY MACROADENOMA Adenoma from inferior pituitary eroded sellar floor, protruded into sphenoid sinus Normal fatty marrow clivus

13 GIANT MACROADENOMA Most common Sellar-Parasellar lesions in Adults Arise from Pituitary gland Burrow into bone Intermediate T2 signal, Solid Enhancement

14 CHORDOMA Bone Erosion Arc-Ring matrix in Chondrosarcoma T2 Hyperintensity Variable Degree of Enhancement

15 CHONDROSARCOMA

16 OSTEOSARCOMA 23 year-old female well-differentiated low-grade type

17 Case 4 VISUAL CHANGE A. Macroadenoma B. Meningioma C. Metastasis D. Chordoma

18 Case 4 MENINGIOMA 2 nd common Parasellar mass in Adults Dural-based Hyperostosis, Enhancing Dural Tail Similar to gray matter, Avid enhancement

19 SELLAR PARASELLAR ENHANCING LESIONS Pituitary origin Adenoma >> Infectious/inflammatory, craniopharyngioma, metastasis Dura origin Meningioma >> Metastasis Clivus origin Chordoma, Chondrosarcoma Metastasis, Plasmacytoma Aneurysm Cavernous ICA, Acom

20 Case 5 HEADACHE

21 Case 5 SELLAR-SUPRASELLAR CYSTIC LESIONS A. Hemorrhagic/Cystic Adenoma B. Rathke s Cleft Cyst C. Epidermoid D. Craniopharyngioma E. Arachnoid cyst

22 CSF + DWI DDx: Dermoid -- Fat EPIDERMOID

23 CRANIOPHARYNGIOMA Bimodal: ½ Childhood Adolescence ½ Adulthood Adamantinoma Children/Adults Wet karatin mass surrounded by inflammatory infiltrate 90 % mixed solid cystic, T1, Ca + Squamous-Papillary Adults Pappilary finger-like projection of squamous epithelium Solid

24 Case 5 CRANIOPHARYNGIOMA Supra-Sellar 75% Sellar-Suprasellar 20% Cystic, Rim-Nodular Ca+80% Multilobulated into multiple anatomic locations Encase vessels, optic nerve Recurrence

25 Case 6 VISUAL CHANGE A. Macroadenoma B. Craniopharyngioma C. Aneurysm D. Germinoma

26 Case 6 MACROADENOMA ACOMM ANEURYSM

27 ACOM ANEURYSM Partial thrombosed Aneurysm: Mixed signal of thrombus

28 Case 1 SEIZURE A. Astrocytoma B. Aneurysm C. Hamartoma D. Epidermoid

29 Case 1 TUBER CINEREUM HAMARTOMA Congenital heterotopia of Gray matter Gelastic seizure Precocious puberty: LHRH secretion

30 Case 7 VISUAL CHANGE HEADACHE A. Craniopharyngioma B. Astrocytoma C. Giant Aneurysm D. Germinoma

31 Case 7 HYPOTHALAMIC-OPTIC CHIASM ASTROCYTOMA 10 year old JPA 60 year old Anaplastic Astrocytoma Children: Low grade, Juvenile Pilocytic Astrocytoma (JPA) Adults: High grade

32 GERMINOMA Suprasellar Pineal

33

34 SUPRASELLAR SOLID LESIONS Aneurysm: Acom, flow artifact, Mixed signal of thrombosis Optic chiasm/hypothalamic Astrocytoma: infiltrative, T2, variable enhancement

35 Case 8 DIPLOPIA CAVERNOUS SINUS LESIONS A. Aneurysm B. Schwannoma C. Lymphoma/Perin eural Spread of Tumor D. Meningioma

36 CAVERNOUS ICA ANEURYSM

37 CAVERNOUS SINUS MENINGIOMA

38 LYMPHOMA SELLAR- CAVERNOUS SINUS Diffuse marrow replacement DDx: Perineural spread of tumor

39 EPIDERMOID CAVERNOUS SINUS

40 Case 8 V1 SCHWANNOMA

41 CAROTID CAVERNOUS FISTULA

42 CAVERNOUS HEMANGIOMA T2 hyperintense T1 Isointense No narrowing ICA Avid nhancement Gradual filling

43 Pituitary Sella Clivus, Sinus Suprasellar Hypothalamus, Optic chiasm, Circle of Willis Parasellar Cavernous Sinus DIFFERENTIALS LOCATIONS CLINICAL

44 MENINGIOMA Narrowing of cavernous ICA Dural tail Petroclival meningioma DDx: Pituitary adenomas, Bone lesion, Lymphoma, Perineural spread of neoplasm, Tolosa-Hunt 45

45 OPHTHALMOPLEGIA 46 2 wks after steroid and chemo Cavernous sinus thrombosis Lymphoma Metastasis Tolosa-Hunt

46 ESRD on HD What Next?

47

48 CAVERNOUS ICA ANEURYSM THROMBUS Concentric ring of thrombus

49 RIGHT FACIAL PAIN Neurilemomas/Schwannoma Intracavernous aneurysms Cavernous hemangiomas 50

50 CAVERNOUS HEMANGIOMA T2 hyper intense Lobular Fill-in

51 MANDIBLE METASTASIS

52 16 YO BOY VISUAL CHANGE

53 HEADACHE

54 CRANIOPHARYNGI OMA Supra-Sellar 75% Sellar-Suprasellar 20% Cystic, Rim-Nodular Ca+80% Multilobulated into multiple anatomic locations Encase vessels, optic nerve Recurrence

55 Thick enhancing pituitary stalk DDx: Germ cell tumor, Sarcoid, Lymphoma

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