PITUITARY PARASELLAR LESIONS

Kim Learned, MD DIFFERENTIALS

• Pituitary • Sella Clivus, Sphenoid Sinus • Suprasellar Optic chiasm, Hypothalamus, Circle of Willis • Parasellar Cavernous Sinus

17 YEAR-OLD FEMALE BITEMPORAL Case 1 SUPERIOR QUADRANTOPSIA

Diffuse gland enlargement

SELLAR-PITUITARY PATHOLOGIES Pituitary • Adenoma • Rathke’s cleft cyst • Apoplexy • 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

PITUITARY Case 3 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

• 2nd 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 EPIDERMOID

• CSF • + DWI • DDx: Dermoid -- Fat CRANIOPHARYNGIOMA

• Bimodal:  ½ Childhood Adolescence  ½ Adulthood

Adamantinoma Squamous-Papillary  Children/Adults  Adults  Wet karatin mass surrounded by  Pappilary finger-like projection inflammatory infiltrate of squamous epithelium  90 % mixed solid cystic, T1 ↑, Ca +  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

TUBER CINEREUM Case 1 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 DIFFERENTIALS LOCATIONS CLINICAL

• Pituitary • Sella Clivus, Sinus • Suprasellar Hypothalamus, Optic chiasm, Circle of Willis • Parasellar Cavernous Sinus

MENINGIOMA

Narrowing of cavernous ICA Dural tail Petroclival meningioma DDx: Pituitary adenomas, Bone lesion, Lymphoma, Perineural spread of neoplasm, Tolosa-Hunt

45 OPHTHALMOPLEGIA

2 wks after steroid and chemo Cavernous sinus thrombosis Lymphoma Metastasis Tolosa-Hunt 46 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