Laurie A. Loevner, MD

Transcription

1 Laurie A. Loevner, MD Chief, Division of Neuroradiology UPHS Professor of Radiology, Otorhinolaryngology: Head & Neck Surgery, Neurosurgery, and Ophthalmology University of Pennsylvania Health System

2 Disclosures Nothing to disclose

3 Review anatomy of the sella and parasellar regions Discuss MRI in the evaluation of sellar masses Illustrate clinical and distinguishing imaging features of sellar lesions Review imaging of adenomas for surgical planning including knosp criteria

4 Sella Infundibulum Suprasellar cistern T1W +C T1W Posterior Lobe Infundibulum Pituicytes (glial) Axons Vasopressin (ADH) Oxytocin

5 T1W -C T1W: CSF dark Fat bright T2W: CSF bright T2W

6 Cavernous Sinus Cranial Nerves III, IV, V1, V2, VI ICA Optic Chiasm Hypothalamus Cor T1W +C Osseous structures Sella turcica Sphenoid sinus Dorsum sella Planum sphenoidale Tuberculum sellae

7 Non-neoplastic lesions Cysts (RCC, pars intermedia) Hyperplasia (physiologic, end organ failure) Primary neoplasms Pituitary adenoma (micro most common) Craniopharyngioma (5% purely intrasellar) Meningioma (purely intrasellar uncommon) Metastasis (1%) Pituitary carcinoma (rare)

8 Clinical Incidental (most) Headache, visual sxs Pituitary dysfunction - hypopit Location Intrasellar - 40% Sellar + Suprasellar - 60%

9 Cor T1W -C MR Imaging Signal varies cyst contents T1 hyperintense 60% Follow CSF 40% No enhancement Sag T1W +C

10 Intra-cystic nodule diagnostic Dark T2 Iso to Bright T1 No enhance Nodule 75% Mucinous material Protein Cholesterol T1W T2W T1W -C T1W +C

11 Intrasellar Rathke s Cleft Cysts FLAIR T1W T2W FLAIR Intrasellar Craniopharyngioma T1W +C

12 Reactive hypertrophy End-organ failure Hypothyroidism Ovarian failure Neuroendocrine tumors Hypothyroidism

13 Microadenoma < 10 mm Enhance < nl gland Stalk deviation GH T1W +C

14 - Grades 0-2 unlikely to have cavernous sinus invasion intra-op - Grades 3 and 4 likely to have cavernous sinus invasion intra-op Neurologyindia.com

15 Knosp

16 Prolactinoma: Knosp 3A T1W +C *

17 T2W T1W T1W +C Cushings: Multiple negative MRIs

18 Adults Pituitary Macroadenoma (50%) Meningioma 10% Craniopharyngioma Aneurysm, Germinoma, Glioma Children Craniopharyngioma most common Chiasmatic / Hypothalamic Glioma Hypothalamic Hamartoma

19 Location: Suprasellar, sellar and suprasellar Imaging Features: Arising from or separate from pituitary gland Cystic degeneration Size sella Infundibulum involved Stalk deviation Relationship to chiasm Edema optic pathways, hypothalmus Cavernous sinus ICA Osseous remodeling

20 Pituitary Macroadenoma > 10 mm Inseparable from pituitary gland Sellar expansion Compression chiasm

21 T1W T1W +C * T2W Flair Macroadenoma * No edema visual paths

22 T1W +C Granulomatous Disease 24 yo headaches, visual changes Normal size sella Separate cavernous sinus lesion Edema optic path and hypothalamus

23 Prolactinoma into Cavernous Sinus Meningioma

24 Meningioma Separate from pituitary Normal size sella Dural enhancement No edema optic tracts FLAIR

25 T2W Meningioma T1W +C T1W +C

26 70% suprasellar with small sellar component 5% purely intrasellar Clinical Visual changes Pituitary dysfunction Mass effect

27 Separate from pituitary Variable signal Ca++ difficult to detect Nodular and peripheral enhancement May have edema optic path T1W +C

28 Adamantinomatous 90% cystic oil, Ca++ FLAIR

29 Craniopharyngioma Papillary type - adults 50% Ca++ Most solid

30

31 Headaches and right visual changes Abnormal pituitary Expanded sella Null Cell Macroadenoma

32 Headaches Separate pituitary gland Chordoma

33 Normal Sella * * Chordoma

34 Pathology Infiltration adenohypophysis lymphocytes, plasma cells? Autoimmune Diabetes insipidus Thickened pituitary stalk

35 Lymphocytic hypophysitis Edema Hypothalamus Flair

36 4 months later Ipilmumab Hypophysitis Drug Induced Hypophysitis monoclonal antibodies Following Treatment

37 Sarcoid Lymphoma Langerhans Histiocytosis

38 Sellar, suprasellar, sellar + suprasellar, infundibulum Stalk deviation Sellar size Osseous remodeling Relationship to chiasm Edema optic pathways, hypothalmus Cavernous sinus ICA Cystic or solid lesions, Ca++