Imaging of Monstrous Craniopharyngioma

NEURORADIOLOGY

H.R. Haghighatkhah MD1 M. Sanei Taheri MD1 Imaging of Monstrous M. Haghighi MD2 S. Shahzadi MD3 Craniopharyngioma: A Pictorial Sh. Birang MD4

Essay

Craniopharyngioma is usually a mixed solid and cystic suprasellar tumor, which usually occurs in children and adults in the fourth and fifth decades of life. The tumors are histologically benign and slow growing, but focal invasion and peritumoral fibrosis leads to high tumoral recurrence after surgery.

We had 11 patients admitted with different symptoms such as headache, nausea, vomiting and visual loss in whom extensive craniopharyngioma was proved after surgery. In some patients, primary imaging studies were reviewed. In others who presented with new onset symptoms several years after surgery, brain CT scan and MRI studies were performed. On brain CT scan of most cases, a mixed cystic and solid suprasellar mass with calcifications in

both solid and cystic parts was detected. In this article, we present some cases of large craniopharyngioma with interesting extensions and invasions to adjacent brain structures. Keywords: Craniopharyngioma, Computed Tomography, Magnetic Reson-

ance Imaging

Introduction

raniopharyngioma is a histologically benign slow-growing tumor (WHO grade Ι),1,2 which accounts for approximately 3% of all intracranial tumors.3,4 C It has a bimodal age distribution with the first peak in children and the second in 1 adults at age 40-60 years. It is not predominant in any sex or race. It originates from the embryonic precursor of adenohypophysis which is called 1. Associate Professor, Department of 1,5,6 Radiology, Shohada Tajrish Hospital, Rathke’s pouch. The adenohypophysis and infandibulum migrate from the Shahid Beheshti University of Medical pharynx to the sella turcica during fetal life. This fact shows that craniopharyn- Sciences, Tehran, Iran. 2. Resident of Radiology, Shohada giomas may occur anywhere along this migration tract.1 Tajrish Hospital, Shahid Beheshti Craniopharyngioma has three histological types: adamantinomatous, papillary University of Medical Sciences, Tehran, Iran. and mixed.1 The adamantinomatous type predominantly occurs in children. 3. Professor of Neurosurgery, Shohada- 1,2,7 Tajrish Hospital, Shahid Beheshti Uni- They are classically cystic tumors with a solid component. The fluid in the versity of Medical Sciences, Tehran, cyst is usually similar to motor oil.8,9 It contains high protein materials, choles- Iran. 4. Associate Professor, Department of terol crystals and blood products. The solid part contains calcification, squamous Radiology, Loghman Hospital, Shahid- or columnar epithelium, fibrosis and inflammation. Complete resection of the Beheshti University of Medical Sciences, Tehran, Iran. tumor is difficult because of this fibrosis and dense adhesion to adjacent structures. This issue leads to frequent recurrence of tumor in patients treated with Corresponding Author Shirin Birang surgery. The papillary type predominantly occurs in adults. It has only a solid Department of Radiology, Loghman component typically without calcification.1,7 This type is more encapsulated and Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. has less recurrence after surgical resection.1 Tel: +9821 5541 1411 Fax: +9821 5541 1411 Because of the slow-growing nature of tumors, the symptoms develop insi- E-mail: [email protected] diously and the common interval between onset of symptoms and diagnosis is 1- 2 Received September 2, 2009; 2 years. The most frequent reported symptoms are headache, nausea, vomiting Accepted after revision March 8, 2010 and visual disturbance. Growth failure and hypogonadism are also encountered

Iran J Radiol 2010;7(2):79-89 frequently. Bitemporal hemianopia is the most frequent disturbance of the visual

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field. Other presentations include seizures, preco- showed a tumoral lesion in the suprasellar region cious puberty, inappropriate secretion of ADH, hear- with extension to the middle and posterior cranial ing loss and epistaxis.10 fossa. The tumor is predominantly cystic with solid In patients with raised intracranial pressure or rapid components. Eggshell calcification is seen in the cys- visual function deterioration, we must focus on sur- tic part. The solid part is also calcified in both pop- gical treatment of hydrocephalus or tumor cyst de- corn and solid lump appearances. Right temporal cra- compression. The main management of tumor is sur- niotomy and an intracystic catheter are noted as well. gery with an attempt to gross total resection of tu- On brain MRI study, the mass is seen with both sol- mor, but in cases with extensive tumors in which to- id and cystic parts. The cystic part is hypointense on tal resection is impossible, limited resection with tu- T1W and hyperintense on T2W images. After con- moral debulking is recommended to reduce the tu- trast injection, homogeneous enhancement is seen in moral compression of optic pathways and to help CSF the solid part and rim enhancement is also seen in the drainage. Limited surgical resections are followed by cystic part. The tumor extends from the suprasellar radiotherapy.2 region to sella and then from the perimesencephalic One of the most interesting issues in craniopharyn- cisterns to the posterior fossa, superior cerebellar cis- gioma imaging is its extension and invasion to mul- tern and cerebellum. It also extended to the right lat- tiple brain structures, which is best appreciated on eral ventricle and third ventricle and produces biven- MRI. These tumors have different patterns of exten- tricular hydrocephalus due to compression of fora- sion such as superior extension from the suprasellar men of Monro. Pathologic examination revealed an region with compression of the third or lateral ven- adamantinomatous craniopharyngioma (Fig. 1). tricles, lateral extension to parasellar areas, cavernous sinuses and temporal lobes, anterior extension to Patient 2 frontal lobes with superior displacement of A1 seg- The second patient is an 11-year-old boy who pre- ment of the anterior cerebral artery and anterior sented with visual loss 1.5 years ago. Brain CT scan communicating artery, posterior extension to perime- revealed a tumoral lesion with both solid and cystic sencephalic cisterns, brain stem, compression of the parts in the suprasellar and sellar regions. Calcifica- basilar trunk and involvement of cerebellum and su- tion is seen in the lesion, which has eggshell configu- perior cerebellar cistern and finally inferior extension ration in the cystic part and lumpy appearance is also to sella, sphenoid and ethmoidal sinuses and nasopha- seen in the solid part. The tumor extends to the post- rynx. Identifying these patterns of extension can help erior cranial fossa. It also extends to the third ven- us in the surgical management of craniopharyngi- tricle from its superior margin. On MRI study, a T1 omas to decide whether total or partial resection is isointense and T2 hyperintense cystic lesion is seen in recommended and to differentiate these tumors from the suprasellar region with extension to sella turcica other extensive skull-base tumoral lesions. and involvement of the left parasellar region with left We encountered 11 patients with surgically con- carotid artery encasement and left cavernous sinus firmed craniopharyngioma. These are extensive tu- invasion. The tumor extended to the posterior fossa mors with unusual extension to their neighboring and compressed the brain stem at its posterior mar- brain structures. Their brain CT scan and MR images gin. It deviated the pons, midbrain and fourth ven- are reviewed. tricle to the right. In addition, it compressed the basilar trunk at its posterior margin. At the superior mar- Case Presentation gin, the tumor extended to the third ventricle and produced biventricular hydrocephalus. After contrast Patient 1 injection, thin rim enhancement was seen in the cystic component and nodular enhancement was en- The first patient is a six-year-old boy who presented countered in the solid part (Fig. 2). with nausea, vomiting and ataxia 2 years after surgical treatment of craniopharyngioma. Brain CT scan

80 Iran J Radiol 2010, 7(2) Monstrous Craniopharyngioma: A Pictorial Essay

A B C

D E F

Fig. 1. A six-year-old boy with nausea, vomiting and ataxia 2 years after surgical treatment of craniopharyngioma. G A. Axial contrast enhanced CT scan of the brain, supra and parasellar cystic tumor with rim enhancement, extension to the posterior fossa and encasement of the basilar artery. B. Axial contrast enhanced CT scan of the brain, cystic and solid tumor with calcification and enhancement of solid and cystic parts, tumoral extension to the third ventricle and posterior fossa is seen. C. Axial contrast enhanced CT scan of the brain, extension of craniopharyngioma to the supratentorial region with compression of Monro's foramen. Drainage catheter is seen in the cystic part. D. Sagittal T1W MRI with contrast, low-signal cystic tumor with rim enhancement, extension to prepontine cistern and invasion to the midbrain and cerebellum. E. Sagittal T1W MRI with contrast, tumoral extension from perimesencephalic cisterns to the posteriorfossa and supratentorial area with biventricular hydrocephalus induction. F. Coronal T1W MRI with contrast, tumoral extension to cerebellum and lateral ventricles. G. Coronal T2W MRI, high signal cystic tumor with compression of the third ventricle.

was seen in the wall of the cystic part after contrast Patient 3 injection. The tumor was adamantinomatous in pa- We encountered a six-year-old girl with headache, thologic examination (Fig. 3). nausea and vomiting from 6 months ago. CT scan of the brain showed a mixed solid and cystic lesion with Patient 4 heavy calcification in the solid and cystic parts. The The fourth patient is a 12-year-old girl who pre- cystic part was seen with hypodense cystic contents. sented with left eye blindness from 5 months ago. On The tumor extended to the right lateral and third brain CT scan performed after stereotaxis and placing ventricles and produces biventricular hydrocephalus. an intracystic catheter, a heavily calcified suprasellar On the MR imaging study, a mixed cystic solid tumor mass with extension to the sella was seen. Erosion with low signal cystic contents on T1W was seen in and destruction of the anterior and posterior clinoid the suprasellar region with extension to the right tha- processes were noted. The mass extended to the ante- lamus and lateral ventricles. Thick rim enhancement rior and posterior cranial fossa. A large cystic compo-

Iran J Radiol 2010, 7(2) 81 Haghighatkhah et al.

A B C

Fig. 2. An 11-year-old boy with visual loss from 1.5 years ago. D A. Axial brain CT scan, suprasellar lesion with calcification of the solid and cystic parts and extension to the posterior fossa. B. Axial brain CT scan, tumoral extension to the third ventricle and compression of the foramen of Monro. C. Axial T1W MRI, tumoral extension to the left parasellar area and left temporal lobe. Invasion to the posterior fossa and brainstem is noted as well. D. Coronal T2W MRI, tumoral extension to the left parasellar area and encasement of the left carotid artery.

A B C

Fig. 3. A six-year-old girl with headache, nausea and vomiting from 6 D months ago. A. Axial brain CT scan, heavily calcified tumor with extension to the third ventricle and biventricular hydrocephalus induction. B. Axial brain CT scan, cystic and calcified tumor with compression of the right lateral ventricle and midline shift to the left. C. Axial T1W MRI, low signal cystic lesion with involvement of the right thalamus. D. Sagittal T1W MRI with contrast, thick rim enhancement of the lesion.

nent was seen in the left frontal region with mass ef- poral lobe which has low signal intensity on T1W fect and midline shift to the right. The MRI study and high signal intensity on T2W images. Nodular was performed one year after surgery, the tumoral enhancement was seen in the periphery of the cystic remnant was seen in the left thalamus and deep tem- part after contrast injection. Pathologic examination

82 Iran J Radiol 2010, 7(2) Monstrous Craniopharyngioma: A Pictorial Essay

revealed adamantinomatous craniopharyngioma (Fig. nal carotid arteries and invasion of both cavernous 4). sinuses are noted as well. A porencephalic area in the right frontal lobe and the drainage catheter are seen Patient 5 on MRI and CT scan. Pathologic examination re- A 17-year-old female was admitted with headache vealed an adamantinomatous craniopharyngioma and epistaxis from one year ago. Seven years ago she (Fig. 6). was operated because of craniopharyngioma. Brain CT scan showed a heavily calcified mixed solid and Patient 7 cystic mass in the suprasellar area with extension to A 5-year-old girl presented with visual loss 3 years the right cerebellopontine angle and third ventricle. after surgical treatment of craniopharyngioma. A cal- Brain MRI revealed a mixed low and high signal in- cified mixed solid and cystic mass was seen in the su- tensity mass on T2W images in the suprasellar area prasellar area on brain CT scan. The tumor extended with extension of cystic part to left temporal lobe and to the third ventricle and posterior fossa in the right right cerebellopontine angle and interpeduncular cis- cerebellopontine angle. Biventricular hydrocephalus terns. It is extended to anterior part of midbrain and was also noted. On T1W brain MRI study, right tem- cerebral peduncles. Low signal areas are seen in tu- poroparietal craniotomy is noted. A mixed solid- moral mass due to calcification. After contrast injec- cystic mass is seen in the suprasellar area with extention, the solid tumoral portion was enhanced densely sion to the third ventricle and compression of lateral and homogeneously. Comprehension of the basilar ventricles with hydrocephalus induction in the right trunk was seen in the posterior aspect of the tumor as lateral ventricle. Low signal cystic materials are noted well as superior displacement of A1 segment of ante- on T1W images. The solid part is seen with high sig- rior cerebral artery (ACA) (Fig. 5). nal intensity in some parts on T1W images probably due to calcification. A multi-cystic mass with low Patient 6 signal areas of calcification is seen on T2W images as A 15-year-old boy was admitted to hospital with well. Encasement of the proximal segment of the headache and bitemporal hemianopia from 14 middle cerebral artery (MCA), ACA, the distal part of months ago. Brain CT scan study was performed 3 the internal carotid artery (ICA) and the basilar trunk years after surgery. A heterogeneous calcified cystic is noted. Invasion to the brain stem from the post- and solid mass was seen in the sellar and suprasellar erior tumoral margin is noted as well (Fig. 7). regions with extension to the anterior and posterior cranial fossae and also to sphenoidal and posterior Patient 8 ethmoidal sinuses and nasopharynx. Anterior and A six-year-old girl was admitted with headache, posterior clinoid processes, sellar floor and sphenoidal nausea and vomiting 3 years after surgical treatment and ethmoidal bones are eroded. At the superior mar- of craniopharyngioma. Physical exam revealed para- gin, the mass extended to the interpeduncular cistern. lysis of lateral gaze in the left eye. Brain CT scan A hypodense area is seen in the right frontal lobe in showed a mixed solid and cystic mass with calcifica- favor of post-surgical encephalomalacic changes. A tion in the suprasellar region with extension to the drainage device is also seen in the cystic part of the left temporal lobe and anterior cisterns of the brain mass. Brain MRI revealed an isointense mass with stem. On MRI study, a T1Wand T2W high signal in- gray matter on T1W images with nodular and rim tensity cystic mass is seen in the suprasellar region enhancement and low signal areas in favor of calcifi- with extension to the left parasellar area and encase- cation. The mass extended to the nasopharynx, post- ment of the left ICA and invasion to the left cavern- erior ethmoidal, left maxillary and sphenoidal sinuses ous sinus and both temporal lobes. Compression and from its inferior margin. It also extended to the post- right deviation of the third ventricle are noted as erior fossa and compresses the brain stem and the ba- well. Midline shift to the right is seen as well as supe- silar trunk. From the superior margin, it extended to rior displacement at A1 segment of the ACA. the interpeduncular cistern. Deviation of both inter-

Iran J Radiol 2010, 7(2) 83 Haghighatkhah et al.

A B

C D

Fig. 4. A 12-year-old girl with left eye blindness from 5 months ago. A. Axial brain CT scan, heavily calcified suprasellar mass with extention to both frontal lobes and posterior fossa. B. Axial brain CT scan, large cystic tumoral part in the left frontal lobe with mass effect and midline shift to the right. C. Sagittal T1W MRI, tumoral recurrence 2 years after operation. D. Sagittal T1W MRI with contrast, nodular and rim enhancement is seen in solid and cystic parts.

A B C D

Fig. 5. A 17-year-old female with headache and epistaxis from one year ago who was admitted 7 years E after surgical treatment of craniopharyngioma. A. Axial brain CT scan, heavily calcified suprasellar mass with extension to the right CP angle. B. Axial brain CT scan, tumoral invasion to the posterior aspect of the third ventricle. C. Axial T2W MRI, mixed solid and cystic tumor of suprasella with low signal areas of calcification, extension to the left temporal lobe and anterior aspect of the midbrain. D. Sagittal T1W MRI, high signal tumor with superior displacement of the A1 segment of ACA. Craniotomy defect is seen at the parietal area. E. Sagittal T1W MRI, tumoral invasion to prepontine cistern and compression of the basilar trunk. enhancement of the solid part are also noted after Patient 9 contrast injection. The mass extends to the right fron- A 23-year-old woman presented with headache, tal lobe and compressed the optic chiasm. Compres- visual loss, nausea and vomiting 6 years after surgical sion of the third ventricular floor is also noted. Pre- treatment of craniopharyngioma. Brain MRI study vious craniotomy scar is seen in the left parietal re- was performed. A multi cystic mass with low signal gion (Fig. 9). intensity on T1W and high signal intensity on T2W images is seen in the sellar and suprasellar regions. Patient 10 Thin rim enhancement of the cystic part and nodular A six-year-old boy was admitted with headache,

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A B C

Fig. 6. A 15-year-old boy with headache and bitemporal D E hemianopia from 14 months ago. A. Axial brain CT scan, suprasellar tumoral mass with calcification and invasion to the sphenoidal and posterior ethmoidal sinuses. Extension to posterior fossa is noted as well. B. Axial contrast enhanced brain CT scan, cystic mass with eggshell calcification and extension to frontal lobes. The drainage catheter and right frontal encephalomala- ciais seen. C. Axial T1W MRI with contrast, nonhomogeneous en- hancing mass with invasion to the posterior fossa, both parasellar areas and posterior ethmoidal sinuses.

D. Axial T1W MRI, tumoral extension to both parasellar areas and encasement of the internal carotid arteries, invasion to both cavernous sinuses is observed. E. Axial T1W MRI with contrast, tumoral invasion to both frontal lobes and compression of anterior aspect of the midbrain.

A B C

Fig. 7. A five-year-old girl with visual loss 3 years after surgical treatment of craniopharyngioma. D A. Axial brain CT scan, solid and cystic calcified suprasellar mass with extension to the right CP angle and compression of the right side of pons. B. Axial brain CT scan, tumoral extension to the third ventricle with biventricular hydrocephalus induction. C. Coronal T1W MRI with contrast, low signal cystic mass with high signal solid parts due to calcification. Mass effect, midline shift and right lateral ventricular hydrocephalus is evident. D. Sagittal T2W MRI, high signal multicystic mass with low signal areas of calcification. Invasion to the brainstem and encasement of the arteries of the circle of Willis is evident.

nausea, vomiting and ataxia from 1.5 years ago. Brain optic chiasm. T1W imaging shows a low signal cystic MRI study was performed. An extensive solid and part extending to the third ventricle with compres- cystic mass is seen in the anterior, middle and post- sion of the foramen of Monro and lateral ventricular erior cranial fossae. The mass had multi-cystic com- hydrocephalus induction. Reticular and non homo- ponents with high and low signal contents on T1W geneous enhancement is seen in the solid parts. Right images. The high signal cystic part extends to the an- and left parasellar extension is noted as well. Post- terior fossa and compresses both frontal lobes and the erior extension to the prepontine and interpeduncu-

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A B C

Fig. 8. A six-year-old girl with headache, nausea and vomiting 3 years after surgical treatment of cra- D niopharyngioma. A. Axial contrast enhanced brain CT scan, mixed solid and cystic suprasellar mass with calcification and extension to the left temporal lobe. B. Axial T1W MRI, high signal suprasellar mass with extension to the left frontal and temporal lobes. C. Axial T2W MRI, high signal cystic mass with extension to the left temporal lobe. D. Coronal T1W MRI, tumoral extension to the left parasellar region with left ICA encasement and left cavernous sinus invasion.

A B C

Fig. 9. A 23-year-old female with headache, visual loss, nausea and vomiting 6 years after surgical treatment of craniophryngioma. A. Coronal T1W MRI with contrast, low signal suprasellar cystic mass with nodular enhancement of the solid part and compression of the third ventricle. B. Sagittal T1W MRI with contrast, tumoral extension to the anterior fossa. C. Axial T2W MRI, high signal cystic tumor with extension to both frontal lobes. lar cisterns with basilar trunk compression is pre- tected. On MRI study, a T1W low signal cystic mass sented (Fig. 10). with iso signal solid parts is seen in the suprasellar region with superior extension to the third ventricle Patient 11 and inferior extension to sella turcica. Encasement of A six-year-old boy presented with testicular en- the left ICA bifurcation and superior displacement at largement from 4 years ago. Brain CT scan was per- M1 segment of the MCA is noted. Posterior extension formed and a hypodense cystic suprasellar mass with to the midbrain and basilar trunk compression is seen superior extension to the third ventricle is noted. as well. Biventricular hydrocephalus is evident on Thin eggshell calcification is also seen in the walls of MRI and CT scan (Fig. 11). the cystic part. Biventricular hydrocephalus is de-

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Fig. 10. A six-year-old boy with headache, A B nausea, vomiting and ataxia from 1.5 years ago. A. Sagittal T1W MRI with contrast, high and low signal multicystic suprasellar mass with rim enhancement in the cystic part. Involve- ment of frontal lobes and third ventricle is seen. B. Coronal T1W MRI with contrast, tumoral invasion to the third ventricle and lateral ventricular hydrocephalus induction.

A B

C D

Fig. 11. A six-year-old boy with testicular enlargement from 4 years ago. A. Axial brain CT scan, cystic suprasellar mass with third ventricular extension and biventricular hydrocephalus induction. Extension to the posterior fossa and brainstem compression is noted as well. B. Axial T1W MRI, low signal suprasellar cystic mass. C. Axial T1W MRI, third ventricular involvement is noted. D. Sagittal T2W MRI, high signal sellar and suprasellar mass with superior displacement of the M1 segment of MCA. hypothalamic or chiasmatic astrocytoma, and even Discussion dermoid or epidermoid cysts may be mimicked by some kinds of extended craniopharyngiomas at imag- Craniopharyngioma is the most common pediatric ing. Being familiar with unusual and interesting im- intracranial tumor of non-glial origin. This tumor aging presentations of these common pediatric tu- should be considered in the differential diagnosis of mors could lead radiologists to a better diagnosis. suprasellar, parasellar, prepontine and posterior fossa Craniopharyngiomas are partly cystic, benign, slow tumors. Rathke cleft cyst, suprasellar, arachnoid cyst, growing, usually suprasellar tumors which account

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for 5-13% of all intracranial tumors.11 They derive leads to high signal characteristics of the cystic part from Rathke’s pouch, the embryonic infolding of en- on T1W images. Cysts are hyperintense on T2W and doderm that extends superiorly from the stomodeum FLAIR images. Solid components appear isointense and gives rise in the early fetal development to the on T1W and heterogeneously iso to hypointense on adenohypophysis;7 with manifestation during child- T2W images. hood and fourth or fifth decades of adult life. Fre- A prominent lipid spectrum is seen in MR spectros- quent symptoms of manifestation are visual symp- copy around 1PPM because of the cystic contents. toms or endocrine disturbances such as polyuria and Also variable signal intensities are seen in diffusion polydipsia due to diabetes insipidus.12 The tumor has weighted images because of variable cystic contents. three histologic types: adamantinomatous (pediatric After contrast injection, patterns of enhancement in type), papillary (adult type) and mixed.1 solid and cystic tumoral parts are similar to CT scan.13 The adamantinomatous type is classically a cystic The location of the tumor is predominantly supra- tumor with solid components.1,2,5 The papillary type is sellar in 75%, supra and infrasellar in 12%, and pure- predominantly solid, without calcification.1,7 After ly intrasellar in 4% of cases. Encasement or displace- surgery and radiation, the 5-year survival rate is more ment of the vessels forming the circle of Willis is than 80% in children. Permanent endocrinologic def- noted. Lateral displacement of ICAs and superior dis- icits are seen in many patients after treatment but location of ACA are also seen. Posterior dislocation visual disturbances are usually reversible. The recur- and compression of the basilar trunk is noted as well. rence rate of the tumor depends on the size of the We can categorize the tumoral extension to three tumor, the recurrence rate is approximately 20% for specific subtypes. In type A, the tumors are entirely tumors smaller than 3 cm and 83% for tumors larger within the sella and vascular displacement is not than 5 cm.1 seen. In type B, the tumor is extended anteriorly be- CT and MRI are complementary studies for detec- tween the optic nerves and pushes the optic chiasm tion of extent and characteristics of the tumor.1 On posteriorly. Elevation of the anterior communicating CT scan, the pediatric type is presented as a predomi- artery and the A1 segment of the anterior cerebral nantly suprasellar and calcified cystic mass with solid artery are noted as well. In type C, elevation of the components in 90% of cases. Extension to sella turci- A1 segment of the anterior cerebral artery and ante- ca is seen frequently. The adult type tumors are rior communicating artery, with posterior compres- usually solid and isodense. Calcifications and intra- sion of the basilar trunk is noted. Anterior dislocation ventricular craniopharyngiomas are rare. of the optic chiasm with third ventricular compres- In the papillary subtype, after contrast injection, sion and hydrocephalus are seen as well.1 enhancement is seen in solid components and the wall of cystic parts in 90% of cases. Anterior and su- References perior extension of the tumor leads to anterior dislocation of the optic chiasm and superior dislocation of 1. Wasserman JR, Koenigsberg RA, Batra K, Gange CP Jr. Craniopha- ryngioma overview. Medscape [serial online] 2008 Jun 11. Available the A1 segment of the anterior cerebral artery. On from: http://emedicine.medscape.corm/article/339424-overview. Ac- CT scan, the usual extension of the cystic part is to cessed April 28, 2009. the anterior and lateral but the solid part extends to 2. Garnett MR, Puget S, Grill J, Sainte-Rose C. Craniopharyngioma. Orphanet J Rare Dis 2007 Apr;2:18. 13 the posterior and lateral. 3. Tsuda M, Takahashi S, Higano S, Kurihara N, Ikeda H, Sakamoto K. MRI is preferred for better determination of the CT and MR imaging of craniopharyngioma. Eur Radiol 1997;7(4):464- 9. tumor extent. The pediatric type appears as a predo- 4. Freeman MP, Kessler RM, Allen JH, Price AC. Craniopharyngioma: minantly cystic mass with solid components but the CT and MRI imaging in nine cases. J Comput Assist Tomogr 1987 papillary type is predominantly solid.1,7 Calcifications Sep-Oct;11(5):810-4. 5. Choi SH, Kwon BJ, Na DG, Kim JH, Han MH, Chang KH. Pituitary are better seen in GRE images and may show suscep- adenoma, craniopharyngioma and Rathke cleft cyst involving both tibility effects. Signal intensity of the cystic part is intrasellar and suprasellar regions: differentiation using MRI. Clin variable on T1W images. Blood products, high pro- Radiol 2007 May;62(5):453-62. tein concentration or cholesterol crystals in the cyst

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