.
This commit is contained in:
Ross
@@ -0,0 +1,213 @@
|
||||
---
|
||||
title: "Intrasellar Lesion"
|
||||
docid: "391834ff-565f-401b-bfbd-0bc40f6b83bf"
|
||||
authors:
|
||||
- key: "e0282a62-994d-4550-a127-1eb773b1e920"
|
||||
value: "Blair A. Winegar, MD"
|
||||
- key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
|
||||
value: "Karen L. Salzman, MD, FACR"
|
||||
- key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
|
||||
value: "Anne G. Osborn, MD, FACR"
|
||||
breadcrumbs:
|
||||
-
|
||||
name: "Brain"
|
||||
slug: "brain"
|
||||
treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
|
||||
-
|
||||
name: "Differential Diagnosis"
|
||||
slug: "differential-diagnosis"
|
||||
treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
|
||||
-
|
||||
name: "Sella/Juxtasellar, Pineal Region"
|
||||
slug: "sellajuxtasellar-pineal-region"
|
||||
treeNodeId: "5e38b9c1-3137-47e3-aa83-1fc82cb4099a"
|
||||
-
|
||||
name: "Anatomically Based Differentials"
|
||||
slug: "anatomically-based-differentials"
|
||||
treeNodeId: "7a51b2ca-8fee-4c16-aff3-b7189f68ea60"
|
||||
-
|
||||
name: "Intrasellar Lesion"
|
||||
slug: "intrasellar-lesion"
|
||||
treeNodeId: null
|
||||
category: "Brain"
|
||||
documentVersionId: "216cd491-5de9-461c-8fdd-c0c0580f06de"
|
||||
imageCount: 21
|
||||
lastUpdated: "03/15/23"
|
||||
pageDescription: "Intrasellar Lesion"
|
||||
pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Intrasellar Lesion"
|
||||
pageTitle: "Intrasellar Lesion | STATdx"
|
||||
enhancedTitle: "Intrasellar Lesion"
|
||||
type: "DDX"
|
||||
references: true
|
||||
breadcrumbs:
|
||||
- "Brain"
|
||||
- "Differential Diagnosis"
|
||||
- "Sella/Juxtasellar, Pineal Region"
|
||||
- "Anatomically Based Differentials"
|
||||
- "Intrasellar Lesion"
|
||||
---
|
||||
# ESSENTIAL INFORMATION
|
||||
|
||||
- ## Key Differential Diagnosis Issues
|
||||
|
||||
|
||||
- Not all "enlarged" pituitary glands are abnormal
|
||||
- Size/height varies with sex, age
|
||||
- Pituitary incidentaloma (cyst, nonfunctioning adenoma) in 15-20% of normal MRs
|
||||
- If it does not enhance, cyst is more likely etiology than microadenoma
|
||||
- ## Helpful Clues for Common Diagnoses
|
||||
|
||||
|
||||
- **Pituitary Hyperplasia**
|
||||
- Physiologic (e.g., young menstruating or postpartum female patients)
|
||||
- Pathologic (end-organ failure, neuroendocrine tumors)
|
||||
- Hypothyroidism is most common etiology
|
||||
- **Pituitary Microadenoma**
|
||||
- < 10 mm in diameter, may enlarge gland
|
||||
- 70-90% hypointense, enhance more slowly than normal pituitary
|
||||
- **Empty Sella**
|
||||
- Intrasellar CSF collection → pituitary gland flattened against sellar floor
|
||||
- 5-10% prevalence on MR
|
||||
- May be associated with idiopathic intracranial hypertension
|
||||
- ## Helpful Clues for Less Common Diagnoses
|
||||
|
||||
|
||||
- **Rathke Cleft Cyst**
|
||||
- T1WI: 50% hypointense, 50% hyperintense
|
||||
- T2WI: 70% hyperintense, 30% isointense/hypointense
|
||||
- Look for intracystic nodule (40-75%)
|
||||
- **Craniopharyngioma**
|
||||
- Completely intrasellar craniopharyngioma uncommon
|
||||
- 90% rule: 90% calcify, 90% cystic, 90% enhance
|
||||
- **Neurosarcoid**
|
||||
- Affects hypothalamic-pituitary axis in ~ 50%
|
||||
- Enhancement along infundibulum ± pituitary gland
|
||||
- ## Helpful Clues for Rare Diagnoses
|
||||
|
||||
|
||||
- **Lymphocytic Hypophysitis**
|
||||
- Autoimmune inflammatory disorder, often pregnant or postpartum females
|
||||
- Enhancing pituitary gland ± stalk
|
||||
- May mimic macroadenoma
|
||||
- **Intracranial Hypotension**
|
||||
- Pituitary enlarged above sella in 50%
|
||||
- Diffuse dural enhancement, slumping brainstem, cerebellar tonsillar ectopia, venous congestion
|
||||
- **Saccular Aneurysm**
|
||||
- Flow void or pulsation artifact may be seen ± lamellated clot
|
||||
- **Lymphoma, Primary CNS**
|
||||
- Often infiltrate adjacent structures
|
||||
- ↓ T2 signal, ↓ ADC value
|
||||
- **CNS Siderosis**
|
||||
- "Black" pituitary gland on T2*
|
||||
- Found with iron overload states > > subarachnoid hemorrhage (thalassemia, hemochromatosis)
|
||||
|
||||
## References
|
||||
|
||||
# Selected References
|
||||
|
||||
1. [Lubomirsky B et al: Sellar, suprasellar, and parasellar masses: imaging features and neurosurgical approaches. Neuroradiol J. 35(3):269-83, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=34856828%5Bpmid%5D)
|
||||
1. [Pascual JM et al: Duct-like recess in the infundibular portion of third ventricle craniopharyngiomas: an MRI sign identifying the papillary type. AJNR Am J Neuroradiol. 43(9):1333-40, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35953277%5Bpmid%5D)
|
||||
1. [Yan S et al: Sellar region lesions and intracranial aneurysms in the era of endoscopic endonasal approach. Front Endocrinol (Lausanne). 12:802426, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=35058885%5Bpmid%5D)
|
||||
1. [Bond KM et al: Spontaneous intracranial hypotension: atypical radiologic appearances, imaging mimickers, and clinical look-alikes. AJNR Am J Neuroradiol. 41(8):1339-47, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32646948%5Bpmid%5D)
|
||||
1. [Sahm F et al: WHO 2016 classification: changes and advancements in the diagnosis of miscellaneous primary CNS tumours. Neuropathol Appl Neurobiol. 44(2):163-71, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=28295484%5Bpmid%5D)
|
||||
1. [Go JL et al: Imaging of the sella and parasellar region. Radiol Clin North Am. 55(1):83-101, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27890190%5Bpmid%5D)
|
||||
1. [Sasagawa Y et al: Clinical characteristics of acromegalic patients with empty sella and their outcomes following transsphenoidal surgery. Pituitary. 20(4):403-8, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28233140%5Bpmid%5D)
|
||||
1. [Kocova M et al: Diagnostic approach in children with unusual symptoms of acquired hypothyroidism. When to look for pituitary hyperplasia? J Pediatr Endocrinol Metab. 29(3):297-303, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26587741%5Bpmid%5D)
|
||||
|
||||
|
||||
## Images
|
||||
|
||||
|
||||
### Selected Images
|
||||
|
||||
|
||||
**Pituitary Hyperplasia**
|
||||
*Coronal T1 C+ MR shows marked enlargement of the pituitary gland <img src='img/arrows/CS.png'/> without focal mass in this 18-year-old woman with hypothyroidism. Pituitary hyperplasia may be physiologic in menstruating, pregnant, or postpartum patients or pathologic, related to end-organ failure.*
|
||||
|
||||
|
||||
**Pituitary Hyperplasia**
|
||||
*Coronal T1 C+ MR shows marked enlargement of the pituitary gland <img src='img/arrows/CS.png'/> without focal mass in this 18-year-old woman with hypothyroidism. Pituitary hyperplasia may be physiologic in menstruating, pregnant, or postpartum patients or pathologic, related to end-organ failure.*
|
||||
|
||||
|
||||
**Pituitary Microadenoma**
|
||||
*Coronal T1 C+ MR shows a hypoenhancing nodule <img src='img/arrows/CS.png'/> in the pituitary gland related to a growth hormone secreting microadenoma in this patient with acromegaly. Prolactinomas are the most common secreting pituitary adenoma.*
|
||||
|
||||
|
||||
**Empty Sella**
|
||||
*Sagittal T1 MR shows an expanded and empty sella <img src='img/arrows/CS.png'/> in this patient with idiopathic intracranial hypertension. There is flattening of the pituitary gland along the sella floor.*
|
||||
|
||||
|
||||
**Pituitary Microadenoma**
|
||||
*Coronal T1 C+ MR in a 43-year-old woman with elevated prolactin shows a hemorrhagic intrasellar macroadenoma <img src='img/arrows/CO.png'/>. Macroadenomas are > 10 mm and most commonly extend through the diaphragma sella into the suprasellar cistern. Displacement of the infundibulum is common.*
|
||||
|
||||
|
||||
**Rathke Cleft Cyst**
|
||||
*Sagittal T1 MR shows an intrinsic hyperintense lesion <img src='img/arrows/WS.png'/> within the pituitary gland between the adenohypophysis anteriorly <img src='img/arrows/CO.png'/> and the neurohypophysis posteriorly <img src='img/arrows/CS.png'/> related to a proteinaceous Rathke cleft cyst. An intracystic nodule may be seen in these benign cystic lesions.*
|
||||
|
||||
|
||||
**Neurosarcoid**
|
||||
*Coronal T1 C+ FS MR shows a sellar and suprasellar mass <img src='img/arrows/CO.png'/> in this 32-year-old with mild prolactin elevation. Note the optic chiasm <img src='img/arrows/WC.png'/> is draped over the mass. Sarcoid was diagnosed at resection. Imaging mimics a macroadenoma.*
|
||||
|
||||
|
||||
**Intracranial Hypotension**
|
||||
*Sagittal T2 FS MR shows a prominent pituitary gland <img src='img/arrows/CS.png'/>, brainstem slumping <img src='img/arrows/CO.png'/>, and cerebellar ectopia <img src='img/arrows/CC.png'/>, consistent with intracranial hypotension.*
|
||||
|
||||
|
||||
**Lymphoma, Primary CNS**
|
||||
*Coronal T1 C+ MR shows a mass lesion diffusely infiltrating and expanding the pituitary gland <img src='img/arrows/CS.png'/>. Note extension into the left cavernous sinus <img src='img/arrows/CO.png'/>, suggesting more aggressive pathology. B-cell lymphoma was diagnosed at biopsy. Lymphoma typically has associated diffusion restriction which can help with an accurate preoperative diagnosis.*
|
||||
|
||||
|
||||
### Additional Images
|
||||
|
||||
|
||||
**Empty Sella**
|
||||
*Sagittal T1 MR shows a partially empty sella <img src='img/arrows/WO.png'/> in this 28-year-old woman with seizures. Note the thinned pituitary gland <img src='img/arrows/CS.png'/> along the sellar floor. The empty sella was incidental in this case but may be associated with idiopathic intracranial hypertension.*
|
||||
|
||||
|
||||
**Rathke Cleft Cyst**
|
||||
*Coronal T2 MR shows an intrasellar Rathke cleft cyst <img src='img/arrows/CS.png'/> with a small intracystic nodule <img src='img/arrows/WO.png'/>. Visualization of an intracystic nodule helps to make an accurate preoperative diagnosis of Rathke cleft cyst. Imaging may mimic a cystic adenoma or a craniopharyngioma, though craniopharyngiomas typically have calcification.*
|
||||
|
||||
|
||||
**Pituitary Hyperplasia**
|
||||
*Coronal T1 C+ MR shows an enlarged pituitary gland in this asymptomatic 28-year-woman. Follow-up scan 1 year later was normal.*
|
||||
|
||||
|
||||
**Rathke Cleft Cyst**
|
||||
*Sagittal T1 MR shows a very hyperintense intrasellar mass <img src='img/arrows/BS.png'/>. The lesion was hypointense on T2 MR. Rathke cleft cyst with inspissated contents was found at surgery.*
|
||||
|
||||
|
||||
**Rathke Cleft Cyst**
|
||||
*Coronal T2 MR shows a hyperintense cystic intrasellar mass <img src='img/arrows/WS.png'/> found incidentally on MR. This is probably a Rathke cleft cyst or pars intermedia cyst.*
|
||||
|
||||
|
||||
**Craniopharyngioma**
|
||||
*Sagittal T1 MR shows a hyperintense intra-/suprasellar mass <img src='img/arrows/CS.png'/> that displaces the pituitary gland <img src='img/arrows/CC.png'/>. Totally intrasellar craniopharyngioma without suprasellar extension is rare.*
|
||||
|
||||
|
||||
**Neurosarcoid**
|
||||
*Coronal T1 C+ MR shows a slightly enlarged pituitary gland <img src='img/arrows/CS.png'/> with a thickened infundibulum above <img src='img/arrows/CC.png'/> in a patient with proven neurosarcoidosis.*
|
||||
|
||||
|
||||
**Intracranial Hypotension**
|
||||
*Sagittal T1 MR shows the classic "slumping midbrain" <img src='img/arrows/CO.png'/> with draping of the optic chiasm over an enlarged pituitary gland <img src='img/arrows/WS.png'/>.*
|
||||
|
||||
|
||||
**"Kissing" Carotid Arteries**
|
||||
*Coronal T2 FS MR shows "kissing" (paramedian) cavernous internal carotid arteries <img src='img/arrows/CS.png'/> projecting medially into the sella turcica. Cavernous internal carotid arteries normally lie laterally within carotid sulcus of sphenoid bone.*
|
||||
|
||||
|
||||
**Metastasis to Gland/Stalk**
|
||||
*Sagittal T1 C+ MR shows a slightly enlarged, inhomogeneously enhancing pituitary gland <img src='img/arrows/CO.png'/> and thickened infundibular stalk <img src='img/arrows/CS.png'/>.*
|
||||
|
||||
|
||||
**Pituitary Microadenoma**
|
||||
*Coronal T2 MR shows a hyperintense intrasellar mass <img src='img/arrows/CS.png'/>. Preoperative diagnosis was Rathke cleft cyst. An almost entirely cystic microadenoma was found at surgery.*
|
||||
|
||||
|
||||
**"Kissing" Carotid Arteries**
|
||||
*Coronal CT angiogram shows medialized course of the bilateral cavernous internal carotid arteries <img src='img/arrows/CS.png'/> compressing the pituitary gland <img src='img/arrows/CO.png'/>, compatible with "kissing" carotid arteries.*
|
||||
|
||||
|
||||
**CNS Siderosis**
|
||||
*Coronal T2* MR in a 9-year-old with long-standing thalassemia major shows a profoundly hypointense pituitary gland <img src='img/arrows/CS.png'/> caused by iron overload syndrome. A hemorrhagic adenoma could have a similar appearance.*
|
||||
|
||||
Reference in New Issue
Block a user