Case Studies in Sella/Parasellar Region No Disclosures 2018 Head and Neck Imaging Conference Child thirsty, increased urination Suprasellar Germ Cell Tumor (Germinoma) Midline Pineal >> Suprasellar > Other Germinoma most common Young patients Diabetes insipidus Imperceptible/small Differential LCH Imaging Fat or thick infundibulum Uniform enhancement + additional sites Absent bright spot Entire neuraxis imaging 1
Adult, worsening vision, increased urination, headaches Pineal Germ Cell Tumor (Germinoma) Child, less active, vomiting 10:1 males/females Metastatic vs. synchronous Hydrocephalus, Parinauld syndrome Differential Other GCT, PPTID, Pineoblastoma Child, worsening headaches 2
Arachnoid Cyst Common, usually incidental Middle cranial fossa >> CPA/suprasellar Child, blurry vision, headache, weakness, ataxia CSF attenuation/signal DWI/FLAIR Epidermoid Resection/fenestration Acute Lymphoblastic Leukemia Initial presentation versus relapse 5% CNS at presentation 50% recur without CNS-directed treatment Leptomeningeal/dural >>> parenchymal Mimic subdural hematoma Differential (pending age) CSF/blood blasts Adult, new onset amenorrhea 3
Microadenoma Incidental/non-functioning Prolactinoma most common functional Adult, months of positional headache, worse at Chiari decompression Dynamic imaging (10-30%) Differential Non-neoplastic cyst Intracranial Hypotension Important to look for signs of ICH if pituitary enlarged Downward displacement of brain Dural enhancement Distended veins/sinuses Subdural collections Problematic if misdiagnose ICH as Chiari I Surgery often exacerbates symptoms (?fatal?) 4
Adult, chronic headaches attributed to sinusitis Rathke s Cleft Cyst (Serous) Adult, vision changes Non-enhancing, non-calcified, sella + suprasellar cyst Nodule helpful (if present!) Appearance dependent on serous/mucoid content Important to not confuse displaced pituitary with solid enhancing features 5
Parasellar Epidermoid CPA >> 4 th ventricle > Parasellar DWI/FLAIR Rare variants dense, white and dark Insinuates (vs. arachnoid cyst displaces) CISS/FIESTA pre-surgical Rare chemical meningitis Dermoid more common Child, am headaches, left pupil dilatation, mild right leg weakness 6
Pilocytic Astrocytoma with CSF Spread Cerebellum >> optic nerve/hypothalamus Young patients (5-15 yrs. of age) Adult, intermittent headaches, memory loss Minimal edema, enhancement WHO Grade I Differential pending location Pilomyxoid astrocytoma 7
Dermoid Cyst Squamous epithelium with dermal elements Infant, hypoglycemia, scalp vascular malformation Sellar region >> other locations Differential: Lipoma, Teratoma (not really) Chemical meningitis versus asymptomatic Septooptic Dysplasia (w/ associations) Myriad of clinical presentations Infant, nasal congestion, failure to grow Associations Small anterior and ectopic posterior pituitary Hypoplastic/absent olfactory nerves Heterotopia/polymicrogyria Schizencephaly Hormone replacement 8
Basal Cephalocele Mesodermal defect in sphenoid, ethmoid, or basiocciput Sphenonasopharyngeal = transsphenoid Most common defect in body of sphenoid bone Associations Callosal dysgenesis, eye abnormalities, midline facial clefts Recurrent meningitis 9
Cavernous Sinus Aneurysm Most asymptomatic, incidental Pain, nerve palsy (III, IV, VI), cavernous sinus syndrome, fistula Monitor versus treatment dependent on many factors Adult, new diagnosis melanoma After therapy Ipilimumab Hypophysitis Post partum, headache Monoclonal Ab to CTLA-4 Augments T-cell activation Mild/moderate enlargement, variable enhancement Infundibulum, anterior lobe Steroids, hormone replacement 10
Pituitary Hyperplasia Upper limit normal height varies Pregnant/lactating: 12 mm Males/postmenopausal female: 8 mm Child, 2 weeks of increased lethargy, loss of appetite, balance Non-physiologic hyperplasia End organ failure, NET, Addison disease, hypothyroidism Homogenous Craniopharyngioma (Child) Suprasellar >> suprasellar + sellar > sellar Adamantinomatous 90% rule: cystic, calcified, enhancing Resection + XRT Important to identify optic chiasm, hypothalamus, and vessels 11
Thank you! 12