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 .