PITUITARY, PARASELLARR AND PITUITARY, PARASELLAR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS

II. PARASELLAR REGION TUMORS

Bert De Foer III. PINEAL REGION TUMORS

MD, PhD, EDiNR, EDiHNR ESHNR vice – president

GZA Hospitals, Antwerp, Belgium

EUROPEAN COURSE IN NEURORADIOLOGY, DIAGNOSTIC and INTERVENTIONAL 15th CYCLE 2nd MODULE ON TUMORS APRIL 29th –MAY 3th 2019, FLANDERS MEETING & CONVENTION CENTRE ANTWERP, BELGIUM

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS I. PITUITARY REGION TUMORS

II. PARASELLAR REGION TUMORS I. IMAGING PROTOCOL II. NORMAL ANATOMY / VARIANTS III. PINEAL REGION TUMORS III. PITUITARY TUMORS / LESIONS

IV. DIFFERENTIAL DIAGNOSIS

II. PARASELLAR REGION TUMORS

III. PINEAL REGION TUMORS

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS IMAGING PROTOCOL : – SELLAR REGION I. IMAGING PROTOCOL • COR TSE T2-WEIGHTED SEQUENCE

II. NORMAL ANATOMY / VARIANTS • COR SE T1-WEIGHTED SEQUENCE • (MRA: 3D TOF MRA) III. PITUITARY TUMORS / LESIONS • COR TSE T1-WEIGHTED – DYNAMIC DURING GD INJECTION IV. DIFFERENTIAL DIAGNOSIS • COR SE T1-WEIGHTED SEQUENCE II. PARASELLAR REGION TUMORS • SAG SE T1-WEIGHTED SEQUENCE

III. PINEAL REGION TUMORS • HALF DOSE OF Gd ! • DIFFUSION-WEIGHTED IMAGING PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS

I. IMAGING PROTOCOL

II. NORMAL ANATOMY / VARIANTS

III. PITUITARY TUMORS / LESIONS COR TSE T2 SAG SE T1 + Gd IV. DIFFERENTIAL DIAGNOSIS

II. PARASELLAR REGION TUMORS

III. PINEAL REGION TUMORS

COR SE T1 COR SE T1 + Gd

COR dyn TSE T1 + Gd

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS

I. IMAGING PROTOCOL

II. NORMAL ANATOMY / VARIANTS

III. PITUITARY TUMORS / LESIONS COR SE T1 - Gd IV. DIFFERENTIAL DIAGNOSIS

II. PARASELLAR REGION TUMORS Courtesy: Elsevier - Amirsys III. PINEAL REGION TUMORS SAG SE T1 + Gd

normal adenohypophysis and normal ‘bright spot’ (PPBS) COR SE T1 - Gd neurohypophysis (vasopressin – children >> adults)

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

6-years-old boy

Short stature, growth hormone deficiency (GHD).

COR SE T1 - Gd

SAG SE T1 + Gd Courtesy: Elsevier - Amirsys

ectopic posterior/neurohypophysis COR SE T1 - Gd + hypoplastic sella/adenohyphysis PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

NOT ALL “ENLARGED PITUITARY GLANDS” ARE ABNORMAL 24-years-old female

• SIZE/HEIGHT VARIES WITH GENDER / AGE Investigation for hyperprolactinemia. • CHILDREN = 6 mm • MALES – POSTMENOPAUZAL FEMALES = 8 mm • YOUNG MENSTRUATING FEMALES = 10 mm (CAN BULGE UPWARDS) • PREGNANT, POSTPARTUM LACTATING FEMALES = 12 mm

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS

I. IMAGING PROTOCOL

II. NORMAL ANATOMY / VARIANTS

III. PITUITARY TUMORS / LESIONS COR TSE T2 SAG SE T1 + Gd IV. DIFFERENTIAL DIAGNOSIS

II. PARASELLAR REGION TUMORS

III. PINEAL REGION TUMORS

COR SE T1 - Gd COR SE T1 + Gd Normal upwards bulging of the hypophysis in a young female

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS 26-years-old female I. IMAGING PROTOCOL Investigation for amenorrhea, galactorrhea and elevated prolactine level. II. NORMAL ANATOMY / VARIANTS

III. PITUITARY TUMORS / LESIONS

IV. DIFFERENTIAL DIAGNOSIS

II. PARASELLAR REGION TUMORS

III. PINEAL REGION TUMORS PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

PITUITARY MICROADENOMA

• TERMINOLOGY • MICROADENOMA: < 10 mm IN DIAMETER

• CLINICAL ISSUES Courtesy: Elsevier - Amirsys COR TSE T2 • SYMPTOMPS OF SECRETING TUMORS VARY ACCORDING TO TYPE • IS MOST COMMON FUNCTIONAL ADENOMA: AMENORRHEA / GALACTHORRHEA / ELEVATED PROLACTINE LEVEL • ASYMPTOMATIC / NON-FUNCTIONING MOST COMMON • 20 – 25% INCIDENTAL FINDING AT AUTOPSY

COR SE T1 • PITUITARY INCIDENTALOMAS: 15-20% of MR SCANS

Left pituitary microadenoma COR dyn TSE T1 + Gd

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

PITUITARY MICROADENOMA 26-years-old female

• IMAGING Investigation for amenorrhea and elevated prolactin level. • INTRASELLAR <<<<<< RARE ECTOPIC • DYNAMIC Gd-ENHANCED TSE T1-WEIGHTED SEQUENCES • GENERALLY ENHANCE but MORE SLOWLY THAN SURROUNDING PITUITARY GLAND • 30% ONLY VISIBLE ON DYNAMIC SEQUENCES • STALK DEVIATION RARE – UNRELIABLE SIGN in MICROADENOMA

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS PITUITARY MACROADENOMA

• TERMINOLOGY • MACROADENOMA : > 10 mm in DIAMETER • “GIANT”: > 4 cm in DIAMETER (<0.5%)

• CLINICAL FEATURES Courtesy: Elsevier - Amirsys COR TSE T2 • MOST OF PITUITARY MACROADENOMAS = NON-FUNCTIONING

SAG SE T1 + Gd • PROLACTINOMA MOST COMMON FUNCTIONAL ADENOMA : AMENORRHEA / GALACTHORRHEA / ELEVATED PROLACTINE LEVE • VERY OFTEN WITHOUT SYMPTOMS • IF SYMPTOMS : OPTIC CHIASM COMPRESSION (HYPERINTENSITY?) • INTRATUMORAL HEMORRAGHE / CYSTS in 10- 20%. COR SE T1 - Gd COR SE T1 + Gd Pituitary macroadenoma (prolactinoma). PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS PITUITARY MACROADENOMA PITUITARY MACROADENOMA

• IMAGING • EXTENSION PATTERN • SELLAR / SUPRASELLAR MASS WITHOUT SEPARATE • USUALLY COMBINED INTRA-/SUPRASELLAR IDENTIFIABLE PITUITARY GLAND • SKULL BASE INVASION • GLAND -> TUMOR • CAVERNOUS SINUS INVASION • “SNOWMAN” – “FIGURE 8” CONFIGURATION • ISOINTENSE TO GRAY MATTER ON T1/T2, • ENHANCES STRONGLY BUT HETEROGENEOUSLY

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

24-years-old female

Investigation for amenorrhea, elevated prolactin level and visual disturbances.

COR TSE T2 SAG TSE T2

SAG SE T1 + Gd

COR SE T1 - Gd COR SE T1 + Gd

Giant pituitary macroadenoma (prolactinoma), with hemorrhagic focus, suprasellar extension and extension in the sphenoid sinus and skull base.

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS PITUITARY MACROADENOMA CAVERNOUS SINUS INVASION • EXTENSION PATTERN • USUALLY COMBINED INTRA-/SUPRASELLAR • CAVERNOUS SINUS INVASION • SKULL BASE INVASION COR SE T1 + Gd • RARE: COMPLETE SKULL BASE INVASION

COR SE T1 + Gd PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

62-years-old male

Investigation by ENT for ‘aural fullness’.

COR and AX CBCT

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS PITUITARY MACROADENOMA

• EXTENSION PATTERN • USUALLY COMBINED INTRA-/SUPRASELLAR • CAVERNOUS SINUS INVASION SAG TSE T2 • SKULL BASE INVASION • RARE: COMPLETE SKULL BASE INVASION • RARE: ECTOPIC • SPHENOID or CAVERNOUS SINUS

AX SE T1 + Gd • CLIVUS • 3rd VENTRICLE, INFUNDIBULUM

Giant pituitary macroadenoma, mainly invading in the skull base. Prolactinoma, treated with Sostilar

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEALPINEAL RREGIONEGION TTUMORSUMORS

44-years-old male

Psychiatric patient with sudden onset of headache and inability to read the newspaper.

CORSE T1 - Gd COR SE T1 + Gd

Pituitary apoplexia with acute hemorraghe in a pituitary macroadenoma PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS PITUITARY APOPLEXIA PITUITARY APOPLEXIA

• CLINICAL FEATURES • IMAGING Courtesy: Elsevier - Amirsys • ACUTE CLINICAL SYNDROME WITH HEADACHE, VISUAL • SELLAR / SUPRASELLAR MASS WITH SIGNS OF HEMORRAGHE DEFECTS, ALTERED MENTAL STATUS, VARIABLE ENDOCRINE • CT: NORMAL/ ENLARGED GLAND WITH PATCHY HYPERDENSITY DEFICIENCIES • HIGH SI ON T1 / IF RECENT, LOW SI ON T2 • PREEXISTING PITUITARY MACROADENOMA COMMON: 65 – 90% • “BLOOMING” ON T2* GRE • ETIOLOGY: HEMORRAGHE / PITUITARY INFARCTION • POSSIBLE FLUID-FLUID LEVELS • M:F = 2:1 • PITUITARY APOPLEXIA IN LESS THAN 1% OF MACROADENOMAS

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

20-years-old female

Visual disturbances

SAG SE T1 - Gd SAG SE T1 + Gd

AX TSE T2

COR SE T1 - Gd AX SE T1 + Gd

Rathke Cleft Cyst

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS RATHKE CLEFT CYST RATHKE CLEFT CYST

• ORIGIN • CLINICALLY • NONNEOPLASTIC CYST ARISING FROM • HEADACHE – VISUAL DEFECT Courtesy: Elsevier - Amirsys REMNANTS OF RATHKE CLEFT • PITUITARY DYSFUNCTION • ENDODERMAL CYST LINED BY CILIATED MUCUS-PRODUCING EPITHELIUM • IMAGING • INTRASELLAR (40 %) – SUPRASELLAR EXTENSION (60%) • NONENHANCING, NONCALCIFIED, INTRASELLAR &/OR SUPRASELLAR CYST – SOMETIMES INTRACYSTIC NODULE • MRI: DEPENDING ON CYST CONTENT • 50% HYPERINTENSE / 50 % ISO-/HYPOINTENSE on T1 • 70% HYPERINTENSE / 30 % ISO-/HYPOINTENSE on T2 • ‘CLAW SIGN’ ENHANCING RIM OF COMPRESSED PITUITARY • 75% ENHANCING NODULE = MORE LIKELY CRANIOPHARYNGOMA PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

66-years-old female

Memory loss and signs of panhypopituitarism

AX GRE T2* AX SE T1 - Gd AX TSE T2

AX SE T1 + Gd

SAG SE T1 + Gd AX UNENHANCED CT

CraniopharyngiomaAX FLAIR

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS CRANIOPHARYNGIOMA

• ORIGIN • CLINICALLY • BENIGN, OFTEN PARTIALLY CYSTIC SELLAR REGION TUMOR • HEADACHE – VISUAL DEFECT Courtesy: Elsevier - Amirsys DERIVED FROM RATHKE POUCH EPITHELIUM • ENDOCRINE DISTURBANCES often GH DEFICIENCY • MOST FREQUENT: CHILDHOOD – ADOLESCENCE / SECOND PEAK 5th –6th DECADE • IMAGING • 2 FROMS ADAMANTINOMATOUS >>> PAPILLARY • CT : CYSTIC (90%), Ca++ (90%), enhancing (90%) • MRI: DEPENDING ON CYST CONTENT • ADAMANTINOMATOUS: CYSTIC MASS – CHILDHOOD • CYST VARIABLE HYPERINTENSE on T1 / T2 • PAPILLARY: SOLID MASS – OLDER ADULTS • SOLID PORTIONS ENHANCE • CA++ ‘BLOOMING’ on GRE T2*

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

64-years-old female

MR investigation for CT incidentaloma of a posterior fossa meningioma

COR SE T1 + Gd

AX TSE T2

‘empty sella’ PITUITARY, PARASELLARR ANDAND PITUITARY, PARASELLARR AND PINEAL REGION TUMORSS PINEAL REGION TUMORS “EMPTY SELLA” 23-years-old obese female

• ORIGIN Courtesy: Elsevier - Amirsys MR investigation for headache. • DEFICIENCY OF DIAPHRAGMA SELLA WITH ENLARGED HIATUS • INTRASELLAR HERNIATION OF ARACHNOID • CLINICALLY • MOSTLY ASYMPTOMATIC • M/F = 1:5 • IMAGING • CT / MRI : CSF FLUID – FILLED SELLA • SELLA USUALLY NORMAL – MAY BE ENLARGED • FLATTENED PITUITARY GLAND • USUALLY MIDLINE

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS IDIOPATHIC INTRACRANIAL HYPERTENSION

• OBESE, YOUNG TO MIDDLE-AGED WOMEN • M:F = 1 ; 4-8 • HEADACHE in 90-95 % - PAPILEDEMA • IMAGING

SAG SE T1 - Gd • EMPTY SELLA • POSTERIOR GLOBE FLATTENING • INTRAOCULAR PROTRUSION OF OPTIC NERVE HEAD • OPTIC NERVE SHEATH ENLARGEMENT – CSF FILLED • OPTIC NERVE TORTUOSITY

AX 3D CISS AX TSE T2 Idiopathic intracranial hypertension

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS I. PITUITARY REGION TUMORS

I. IMAGING PROTOCOL I. IMAGING PROTOCOL

II. NORMAL ANATOMY / VARIANTS II. NORMAL ANATOMY / VARIANTS

III. PITUITARY TUMORS / LESIONS III. PITUITARY TUMORS / LESIONS

IV. DIFFERENTIAL DIAGNOSIS IV. DIFFERENTIAL DIAGNOSIS

II. PARASELLAR REGION TUMORS II. PARASELLAR REGION TUMORS

III. PINEAL REGION TUMORS III. PINEAL REGION TUMORS PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

39-years-old male

MR investigation for visual disturbances

AX TSE T2 SAG SE T1 - Gd SAG SE T1 + Gd

Courtesy: Marc Lemmerling Ghent, Belgium

COR SE T1 - Gd COR SE T1 + Gd

Suprasellar meningioma

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS MENINGIOMA MENINGIOMA

• 10% OF MENINGIOMAS: PARASELLAR >>>SUPRASELLAR • IMAGING • ORIGIN • T1: ISOINTENSE – STRONG ENHANCEMENT • TUBERCULUM SELLAE • T2: HYPER/ISOINTENSE • CLINOID PROCESS • “DURAL TAIL” • MEDIAL SPHENOID WING • HYPEROSTOSIS • CAVERNOUS SINUS • CSF CLEFT BETWEEN MENINGIOMA AND BRAIN • DIAPHRAGMA SELLAE • SEPARATION FROM PITUITARY GLAND • VASCULAR ENCASEMENT WITH LUMEN CONSTRICTION !

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

39-years-old female

Headache, right-sided visual loss, right-sided sensory loss in the face

SAG SE T1-Gd AX TSE T2 AX b1000 DWI

SAG SE T1 - Gd AX FLAIR AX ADC map PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS METASTASIS

• ORIGIN : 5% OF ALL CANCER PATIENTS • HEMATOGENIC SPREAD TO PITUITARY GLAND • DURAL SPREAD AND/OR CSF SPREADING • DIRECT INVASION OF A HEAD AND NECK NEOPLASM

• CLINICAL FINDINGS • ASYMPTOMATIC • HEADACHE • PITUITARY HYPOFUNCTION AXSE T1+Gd

• IMAGING • ASPECIFIC COR SE T1+Gd • USUALLY NO PITUITARY FOSSA ENLARGEMENT PriorMetastatic history malignant of a superficial melanoma spreading malignant melanoma Clark III, Breslow-index 0,9

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

40-years-old male

Diabetes insipidus and panhypopituitarism

SAG SE T1 - Gd COR TSE T2

SAG SE T1 + Gd Courtesy: Paul Parizel, Christoph Kenis Antwerp, Belgium COR SE T1 - Gd COR SE T1 + Gd

Lymphocytic hypophysitis

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS LYMPHOCYTIC HYPOPHYSITIS LYMPHOCYTIC HYPOPHYSITIS

• ORIGIN Courtesy: Elsevier - Amirsys • IMAGING FINDINGS • IDIOPATHIC, AUTOIMMUNE INFLAMMATION OF • MASS LESION PITUITARY GLAND AND STALK • THICK STALK +/- PITUITARY , HYPOTHALAMIC MASS • DEPENDING ON LOCATION: • CLINICAL FINDINGS -> DEPENDING UPON LOCATION • ADENOHYPOPHYSITIS: ENLARGED PITUITARY GLAND • MAY MIMIC PITUITARY APOPLEXY • INFUNDIBULONEUROHYPOPHISITIS: DIABETES INSIPIDUS • INFUNDIBULOHYPOPHYSITIS: • PANHYPOPHYSITIS: COMBINATION OF ANTERIOR AND • MASS IN STALK POSTERIOR SIGNS / SYMPTOMS • MASS IN MEDIAN EMINENCE OF • PANHYPOPHYSITIS: ALL OF THE ABOVE PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

17-years-old male

Seizures

COR TSE T2 COR SE T1 - Gd COR SE T1 + Gd

SAG SE T1 + Gd High grade hypothalamic

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS HYPOTHALAMIC ASTROCYTOMA 14-years-old female • MOST COMMON PRIMARY NEOPLASM OF HYPOTHALAMIC-OPTIC CHIASM REGION Gelastic seizures • USUALLY LOW GRADE – OFTEN PILOCYTIC • AGE: OFTEN VERY YOUNG, < 5 y • ENDOCRINE DYSFUNCTION IN 20% • LOOK FOR EVIDENCE OF NF1 • IMAGING: • INHOMOGENEOUS ENHANCING MASS LESION • IF PILOCYTIC = CYSTIC

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

• NONNEOPLASTIC CONGENITAL GRAY MATTER HETEROTOPIA

• CLINICAL • AT VERY YOUNG AGE • REFRACTORY MIXED SEIZURE TYPE • DEPRESSION, ANXIETY

• IMAGING • NONENHANCING HYPOTHALAMIC MASS CONTIGUOUS WITH SAG SE T1 - Gd SAG SE T1 + Gd Courtesy: TUBER CINEREUM Christoph Kenis Heusden-Zolder, Belgium • CAN BE SESSILE OR PEDUNCULATED • BETWEEN MAMILLARY BODIES AND INFUNDIBULUM

Tuber cinereum hamartoma PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS

II. PARASELLAR REGION TUMORS

III. PINEAL REGION TUMORS

Courtesy: Elsevier - Amirsys

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS Meninges Meninges Carotid Artery Carotid Artery

Nerves Nerves

Bone – Sutures Bone – Sutures Nasopharynx Nasopharynx

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

67-years-old female

CT investigation as primary imaging for ‘headache’

Unenhanced CT Contrast-enhanced CT Large, saccular carotid siphon aneurysm PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS Meninges CAROTID ANEURYSM Carotid Artery

• ORIGIN • CAVERNOUS PORTION / SUPRACLINOID CAROTID ARTERY • OCCASIONALLY ACA, PCA, BASILAR • CT • SLIGHTLY HYPERDENSE / CALCIFICATIONS • STRONG ENHANCEMENT • ECCENTRIC LOCATION • MRI Nerves • “FLOW VOIDS” • MIXED SIGNALS IF (PARTIALLY) THROMBOSED • IF DOUBT: MRA Bone – Sutures Nasopharynx

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

70-years-old male

Prior surgery of basocellular and spinocellular carcinoma at the forehead. Presents with pain and sensory loss on the forehead on the right side.

COR SE T1 + Gd Perineural spread along the supraorbital nerve, the frontal nerve, the ophtalmic nerve and the trigeminal nerve

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS Meninges PERINEURAL TUMOR SPREAD Carotid Artery

• ORIGIN • MOST FREQUENT ALONG CNV AND CNVII • ADENOID CYSTIC CARCINOMA, SQUAMOUS CELL CARCINOMA, LYMPHOMA, MELANOMA… • CT • OFTEN VERY SUBTLE • NERVE THICKENING AND ENHANCEMENT • ENLARGED NEUROFORAMINAE Nerves • MRI • LOS OF FAT SIGNAL ALONG COURSE OF THE NERVE ON T1 • ENLARGED AND ENHANCED NERVE ON T1 Bone – Sutures Nasopharynx PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

COR CT scan 57-years-old male COR SE T1 + Gd

The picture can't be displayed.

Prior CT / RT treatment for a nasopharyngeal carcinoma. Presents with right-sided hemifacial pain and abducens paresis.

Direct ‘per continuitatem’ invasion COR SE T1 + Gd of a recurrent nasopharyngeal carcinoma

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS Meninges Carotid Artery 52-years-old female

Investigation for headache and right-sided trigeminal neuralgia

Nerves

Bone – Sutures Nasopharynx

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGIONEGION TTUMORSUMORS

52-years-old female

Investigation for headache and right-sided trigeminal neuralgia COR SE T1 - Gd

AX TSE T2 COR SE T1 + Gd

Chondrosarcoma PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS Meninges SKULL BASE CHONDROSARCOMA Carotid Artery

• ORIGIN • TYPICAL LOCATION OFF-MIDLINE • (IF MIDLINE – CHORDOMA) • PETRO-OCCIPITAL FISSURE • CT • CHONDROID TUMOR MATRIX CALCIFICATIONS IN 50% • ARC OR RING-LIKE CALCIFICATIONS • MRI Nerves • HIGH T2 SIGNAL !! • (HETEROGENEOUSLY) ENHANCEMENT • ‘RING AND ARCS’ Bone – Sutures Nasopharynx

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS

COR SE T1 - Gd COR SE T1 + Gd 64-years-old female

Right-sided visual loss and trigeminal neuralgia

COR SE T1 + Gd COR SE T1 + Gd

Large right-sided parasellar meningioma

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGION TUMORS I. PITUITARY REGION TUMORS TUMORS OF THE PINEAL REGION = 14-27 % • CHILDREN 3%-8% II. PARASELLAR REGION TUMORS INTRACRANIAL NEOPLASMS = 40 % • ADULTS < 1% of INTRACRANIAL III. PINEAL REGION TUMORS NEOPLASMS • GERM CELL TUMORS AND PINEAL PARENCHYMAL TUMORS DO NOT DISPLAY PATHOGNOMONIC IMAGING FEATURES • GERM CELL TUMORS MAY BE HORMONALLY ACTIVE • IN CASE OF MALIGNANCY: METS ! • PINEAL CYST – ARACHNOID CYST = / > CSF SIGNAL Smith AB, Radiographics 2010;30:2001-20 Fang AS, Insights Imaging 2013; 4: 369-382 PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND PINEAL REGION TUMORS PINEAL REGIONON TTUMORSUMORS • 14-60% PPL • ADULTS TUMORS OF THE PINEAL REGION • WHO I • ‘EXPLOSION’ • CLINICAL FEATURES DUE TO COMPRESSION OF TECTAL PLATE OF Ca2+ AND OBSTRUCTIVE HYDROCEPHALUS • SEIZURES • 50% PPL • HEADACHE • CHILDREN • WHO IV • NAUSEA AND VOMITING • ENHANCEMENT • INFILTRATIVE LESIONS • NECROSIS • PRECOCIOUS PUBERTY • DWI: RESTRICTION • PARINAUD SYNDROME • BAD PROGNOSIS • PINEAL APOPLEXY

Courtesy: Luc Van Den Hauwe, Antwerp, Belgium

PITUITARY, PARASELLARR AND PITUITARY, PARASELLARR AND

PINEAL REGIONGION TTUMORSUMOR• 50% - 70 % of ALL PINEAL REGION TUMORS PINEAL TUMORS • 90% < 20 y TAKE HOME MESSAGES • M >>>>F • DISSEMINATION • DYNAMIC Gd ENHANCED T1-WEIGHTED SEQUENCES VERY COMMON • HALVE DOSE of Gd • GOOD PROGNOSIS • MRI CYSTS • MAJORITY OF ADENOMAS IS NON-FUNCTIONING/NON-SECRETING • MAJORITY OF LESIONS: MICRO- AND MACROADENOMATA • 1-4 of all MRI’s • EXTENSION: (SUPRA)SELLAR – SKULL BASE – SPHENOID SINUS • 20-40 AUTOPSY • CLINICAL INFORMATION – THERAPY • SI CSF or HIGHER • DD MENINGIOMA – ANEURYSMS • FLAIR HIGHER SI • THIN RIM OF ENHANCEMENT

Courtesy: Luc Van Den Hauwe, Antwerp, Belgium

PITUITARY, PARASELLARR AND PINEAL REGION TUMORS

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