PITUITARY PARASELLAR LESIONS Kim Learned, MD
DIFFERENTIALS Pituitary Sella Clivus, Sphenoid Sinus Suprasellar Optic chiasm, Hypothalamus, Circle of Willis Parasellar Cavernous Sinus
Case 1 17 YEAR-OLD FEMALE BITEMPORAL SUPERIOR QUADRANTOPSIA Diffuse gland enlargement
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)
PITUITARY ADENOMA Microadenoma < 10 mm Local mass effect Deviation of normal pituitary Stalk and Gland
PITUITARY ADENOMA Hemorrhagic Cystic changes Cavernous sinus Protrusion (ICA abutment < 180) Invasion (ICA abutment >270)
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
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
Case 1 LYMPHOCYTIC HYPOPHYSITIS Diffuse infiltration of the gland with convex contour, elevation-thickening of the stalk
DIFFUSE PITUITARY GLAND PROCESS Hyperplasia Macroadenoma Infiltrative processes lymphocytic hypophysitis, sarcoid, granulomatous disease
Case 3 INCIDENTAL FINDINGS A. Pituitary adenoma B. Sinonasal tumor C. Chordoma D. All above
Case 3 PITUITARY MACROADENOMA Adenoma from inferior pituitary eroded sellar floor, protruded into sphenoid sinus Normal fatty marrow clivus
GIANT MACROADENOMA Most common Sellar-Parasellar lesions in Adults Arise from Pituitary gland Burrow into bone Intermediate T2 signal, Solid Enhancement
CHORDOMA Bone Erosion Arc-Ring matrix in Chondrosarcoma T2 Hyperintensity Variable Degree of Enhancement
CHONDROSARCOMA
OSTEOSARCOMA 23 year-old female well-differentiated low-grade type
Case 4 VISUAL CHANGE A. Macroadenoma B. Meningioma C. Metastasis D. Chordoma
Case 4 MENINGIOMA 2 nd common Parasellar mass in Adults Dural-based Hyperostosis, Enhancing Dural Tail Similar to gray matter, Avid enhancement
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
Case 5 HEADACHE
Case 5 SELLAR-SUPRASELLAR CYSTIC LESIONS A. Hemorrhagic/Cystic Adenoma B. Rathke s Cleft Cyst C. Epidermoid D. Craniopharyngioma E. Arachnoid cyst
CSF + DWI DDx: Dermoid -- Fat EPIDERMOID
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
Case 5 CRANIOPHARYNGIOMA Supra-Sellar 75% Sellar-Suprasellar 20% Cystic, Rim-Nodular Ca+80% Multilobulated into multiple anatomic locations Encase vessels, optic nerve Recurrence
Case 6 VISUAL CHANGE A. Macroadenoma B. Craniopharyngioma C. Aneurysm D. Germinoma
Case 6 MACROADENOMA ACOMM ANEURYSM
ACOM ANEURYSM Partial thrombosed Aneurysm: Mixed signal of thrombus
Case 1 SEIZURE A. Astrocytoma B. Aneurysm C. Hamartoma D. Epidermoid
Case 1 TUBER CINEREUM HAMARTOMA Congenital heterotopia of Gray matter Gelastic seizure Precocious puberty: LHRH secretion
Case 7 VISUAL CHANGE HEADACHE A. Craniopharyngioma B. Astrocytoma C. Giant Aneurysm D. Germinoma
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
GERMINOMA Suprasellar Pineal
SUPRASELLAR SOLID LESIONS Aneurysm: Acom, flow artifact, Mixed signal of thrombosis Optic chiasm/hypothalamic Astrocytoma: infiltrative, T2, variable enhancement
Case 8 DIPLOPIA CAVERNOUS SINUS LESIONS A. Aneurysm B. Schwannoma C. Lymphoma/Perin eural Spread of Tumor D. Meningioma
CAVERNOUS ICA ANEURYSM
CAVERNOUS SINUS MENINGIOMA
LYMPHOMA SELLAR- CAVERNOUS SINUS Diffuse marrow replacement DDx: Perineural spread of tumor
EPIDERMOID CAVERNOUS SINUS
Case 8 V1 SCHWANNOMA
CAROTID CAVERNOUS FISTULA
CAVERNOUS HEMANGIOMA T2 hyperintense T1 Isointense No narrowing ICA Avid nhancement Gradual filling
Pituitary Sella Clivus, Sinus Suprasellar Hypothalamus, Optic chiasm, Circle of Willis Parasellar Cavernous Sinus DIFFERENTIALS LOCATIONS CLINICAL
MENINGIOMA Narrowing of cavernous ICA Dural tail Petroclival meningioma DDx: Pituitary adenomas, Bone lesion, Lymphoma, Perineural spread of neoplasm, Tolosa-Hunt 45
OPHTHALMOPLEGIA 46 2 wks after steroid and chemo Cavernous sinus thrombosis Lymphoma Metastasis Tolosa-Hunt
ESRD on HD What Next?
CAVERNOUS ICA ANEURYSM THROMBUS Concentric ring of thrombus
RIGHT FACIAL PAIN Neurilemomas/Schwannoma Intracavernous aneurysms Cavernous hemangiomas 50
CAVERNOUS HEMANGIOMA T2 hyper intense Lobular Fill-in
MANDIBLE METASTASIS
16 YO BOY VISUAL CHANGE
HEADACHE
CRANIOPHARYNGI OMA Supra-Sellar 75% Sellar-Suprasellar 20% Cystic, Rim-Nodular Ca+80% Multilobulated into multiple anatomic locations Encase vessels, optic nerve Recurrence
Thick enhancing pituitary stalk DDx: Germ cell tumor, Sarcoid, Lymphoma