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 : PITUITARY GLAND – 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 posterior pituitary ‘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 • PROLACTINOMA 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 PITUITARY ADENOMA • 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