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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