226 lines
21 KiB
Markdown
226 lines
21 KiB
Markdown
---
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title: "Cystic Intrasellar Mass"
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docid: "e5a24511-dd27-495c-b20a-c56534351a06"
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authors:
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- key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
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value: "Karen L. Salzman, MD, FACR"
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- key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
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value: "Anne G. Osborn, MD, FACR"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
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-
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name: "Sella/Juxtasellar, Pineal Region"
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slug: "sellajuxtasellar-pineal-region"
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treeNodeId: "5e38b9c1-3137-47e3-aa83-1fc82cb4099a"
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-
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name: "Anatomically Based Differentials"
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slug: "anatomically-based-differentials"
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treeNodeId: "7a51b2ca-8fee-4c16-aff3-b7189f68ea60"
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-
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name: "Cystic Intrasellar Mass"
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slug: "cystic-intrasellar-mass"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "853dca59-915a-4a45-8c80-d20bbbfd9733"
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imageCount: 23
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lastUpdated: "01/24/23"
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pageDescription: "Cystic Intrasellar Mass"
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pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Cystic Intrasellar Mass"
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pageTitle: "Cystic Intrasellar Mass | STATdx"
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enhancedTitle: "Cystic Intrasellar Mass"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Differential Diagnosis"
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- "Sella/Juxtasellar, Pineal Region"
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- "Anatomically Based Differentials"
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- "Cystic Intrasellar Mass"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Cystic mass originating **within** sella turcica vs. intrasellar extension from suprasellar lesion
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- Intrasellar extension of suprasellar lesion > intrasellar mass
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- ## Helpful Clues for Common Diagnoses
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- **Empty Sella**
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- Small crescent of compressed pituitary gland lines bottom of sella turcica
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- Primary empty sella considered normal variant
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- Secondary = surgery, pituitary infarction
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- **Intracranial****H****ypertension, Idiopathic**
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- Pseudotumor cerebri: F > > M
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- Empty sella ± dilated optic nerve sheaths, small ventricles, transverse sinus/sigmoid sinus junction stenosis
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- Obese female with headaches
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- **Cystic Pituitary Adenoma**
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- May be functional, often prolactinoma, or null cell
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- Small (≤ 10 mm), enhances < gland
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- ## Helpful Clues for Less Common Diagnoses
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- **Rathke Cleft Cyst**
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- Usually < 1 cm; may be giant, erode sella
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- 40-75% have intracystic nodule
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- ± claw sign (enhancing rim of pituitary around nonenhancing cyst)
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- **Craniopharyngioma**
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- Truly intrasellar craniopharyngioma rare
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- If no Ca⁺⁺, difficult to distinguish from Rathke cleft cyst
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- 90% rule (adamantinomatous): 90% calcify, 90% cystic, 90% enhance
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- ## Helpful Clues for Rare Diagnoses
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- **Pituitary****A****poplexy**
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- Can be life threatening (secondary to pituitary insufficiency)
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- Acutely may present as necrotic, rim-enhancing mass
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- Typically sellar and suprasellar
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- **Arachnoid Cyst**
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- Truly intrasellar arachnoid cyst (AC) rare
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- Usually extension from suprasellar AC
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- **Neurocysticercosis Cyst**
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- Suprasellar cysts → intrasellar
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- May have racemose cysts in basal cisterns
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- **Epidermoid Cyst**
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- Suprasellar < off-midline location
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- T2 hyperintense, DWI hyperintense
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- **Saccular Aneurysm****(Thrombosed)**
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- Medially projecting from cavernous ICA
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- If thrombosed, may appear low signal intensity on T1 C+ scans
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- **Par Intermedia Cyst**
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- Benign cyst in between adenohypophysis and neurohypophysis
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- **Obstructive Hydrocephalus (Mimic)**
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- Anterior recesses of 3rd ventricle enlarge
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- Herniate inferiorly into sella
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- If chronic may expand, erode bony sella
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## References
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# Selected References
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1. [Kuzan BN et al: Accuracy and reliability of magnetic resonance imaging in the diagnosis of idiopathic intracranial hypertension. Eur J Radiol. 155:110491, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36007323%5Bpmid%5D)
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1. [Azuma M et al: Added value of contrast-enhanced 3D-FLAIR MR imaging for differentiating cystic pituitary adenoma from Rathke's cleft cyst. Magn Reson Med Sci. 20(4):404-9, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33487606%5Bpmid%5D)
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1. [Belachew NF et al: Evolution of MRI findings in patients with idiopathic intracranial hypertension after venous sinus stenting. AJNR Am J Neuroradiol. 42(11):1993-2000, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34620591%5Bpmid%5D)
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1. [Azuma M et al: Usefulness of contrast-enhanced 3D-FLAIR MR imaging for differentiating Rathke cleft cyst from cystic craniopharyngioma. AJNR Am J Neuroradiol. 41(1):106-10, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31857323%5Bpmid%5D)
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1. [Kuan EC et al: Treatment outcomes of Rathke's cleft cysts managed with marsupialization. J Neurol Surg B Skull Base. 78(2):112-5, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28321372%5Bpmid%5D)
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1. [Morris PP et al: Transverse sinus stenosis is the most sensitive MR imaging correlate of idiopathic intracranial hypertension. AJNR Am J Neuroradiol. 38(3):471-7, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28104635%5Bpmid%5D)
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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)
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1. [Sivaraju L et al: Giant multi-compartmental suprasellar Rathke's cleft cyst with restriction on diffusion weighted images. Neuroradiol J. 1971400916682512, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28059626%5Bpmid%5D)
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1. [Zhang X et al: Sellar cysticercosis and septum pellucidum cyst: a case report and review of the literature. Southeast Asian J Trop Med Public Health. 45(3):584-7, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24974642%5Bpmid%5D)
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1. [Saindane AM et al: Factors determining the clinical significance of an "empty" sella turcica. AJR Am J Roentgenol. 200(5):1125-31, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23617499%5Bpmid%5D)
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1. [Arriada-Mendicoa N et al: Imaging features of sellar cysticercosis. AJNR Am J Neuroradiol. 24(7):1386-9, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12917134%5Bpmid%5D)
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## Images
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### Selected Images
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**Empty Sella**
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*Sagittal T1WI MR shows empty sella with herniation of CSF through the diaphragma sellae <img src='img/arrows/WS.png'/>, flattening the pituitary gland inferiorly against the sellar floor <img src='img/arrows/CO.png'/>. Empty sella may be asymptomatic or may be associated with idiopathic intracranial hypertension.*
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**Empty Sella**
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*Sagittal T1WI MR shows empty sella with herniation of CSF through the diaphragma sellae <img src='img/arrows/WS.png'/>, flattening the pituitary gland inferiorly against the sellar floor <img src='img/arrows/CO.png'/>. Empty sella may be asymptomatic or may be associated with idiopathic intracranial hypertension.*
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**Intracranial Hypertension, Idiopathic**
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*Axial T2WI FS MR in a young female with headaches shows classic features of idiopathic intracranial hypertension with an empty sella <img src='img/arrows/BS.png'/>, dilatation of the optic nerve sheaths <img src='img/arrows/WO.png'/>, and prominent optic nerve heads <img src='img/arrows/CS.png'/>, related to papilledema.*
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**Cystic Pituitary Adenoma**
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*Coronal T2WI MR shows a cystic microadenoma <img src='img/arrows/CO.png'/> in the right pituitary gland. Microadenomas may be asymptomatic or may present with abnormal endocrine values, commonly elevated prolactin. When cystic, microadenomas mimic benign cysts, such as Rathke cleft cysts.*
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**Rathke Cleft Cyst**
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*Sagittal T1WI C+ MR shows an intrasellar Rathke cleft cyst <img src='img/arrows/CO.png'/> as a CSF-like mass that displaces the normal pituitary gland anteriorly <img src='img/arrows/WS.png'/>, forming a claw sign. Often, a nonenhancing, intracystic nodule may be seen.*
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**Craniopharyngioma**
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*Sagittal T2WI MR shows a cystic sellar and suprasellar mass <img src='img/arrows/CO.png'/>.Calcification and enhancement help differentiate craniopharyngioma from Rathke cleft cyst. Only 5% of craniopharyngiomas are purely intrasellar.*
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**Pituitary Apoplexy**
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*Coronal T2WI MR shows a cystic sellar and suprasellar mass <img src='img/arrows/CS.png'/> in a 40-year-old male patient with acute onset of headache and cranial neuropathy. Pituitary apoplexy may result from hemorrhage or infarction of a macroadenoma, as in this patient.*
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**Arachnoid Cyst**
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*Coronal T1WI C+ MR shows a sellar and suprasellar arachnoid cyst <img src='img/arrows/CO.png'/> with leftward displacement of the pituitary infundibulum <img src='img/arrows/WS.png'/>. Note the pituitary gland <img src='img/arrows/WC.png'/> is flattened beneath the cyst. Arachnoid cysts follow CSF signal intensity on all sequences.*
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**Obstructive Hydrocephalus (Mimic)**
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*Sagittal T2WI SPACE MR shows obstructive hydrocephalus related to a cystic lesion at the anterior cerebral aqueduct <img src='img/arrows/WS.png'/>. Note mild enlargement of bony sella <img src='img/arrows/BS.png'/> and suprasellar herniation of the anterior 3rd ventricle <img src='img/arrows/CC.png'/>.*
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### Additional Images
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**Arachnoid Cyst**
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*Sagittal T1WI MR shows a sellar and suprasellar arachnoid cyst <img src='img/arrows/CO.png'/>. Note the pituitary gland <img src='img/arrows/WS.png'/> is stretched anteriorly around the cyst. Arachnoid cysts follow CSF signal intensity on all sequences.*
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**Epidermoid Cyst**
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*Axial T2WI MR shows a large epidermoid cyst extending into the sella and suprasellar subarachnoid space <img src='img/arrows/CC.png'/>. Epidermoids are congenital lesions that classically show DWI hyperintensity. They are most commonly found in the cerebellopontine angle.*
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**Craniopharyngioma**
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*Coronal T2WI MR shows a CSF-like intrasellar mass <img src='img/arrows/CO.png'/>. Surgery disclosed intrasellar craniopharyngioma with only a small suprasellar component. Calcification and enhancement help differentiate craniopharyngioma from a Rathke cleft cyst. Only 5% of craniopharyngiomas are purely intrasellar.*
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**Obstructive Hydrocephalus (Mimic)**
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*Sagittal T2WI MR shows aqueductal stenosis <img src='img/arrows/WC.png'/> with severe obstructive hydrocephalus. Note marked enlargement of bony sella <img src='img/arrows/WS.png'/> and intrasellar herniation of the inferior 3rd ventricle <img src='img/arrows/BC.png'/>.*
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**Pituitary Apoplexy**
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*Coronal T1WI C+ MR shows rim <img src='img/arrows/WS.png'/> and nodular <img src='img/arrows/WO.png'/> enhancement around necrotic macroadenoma in a patient with sudden onset of visual problems and pituitary insufficiency.*
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**Pituitary Apoplexy**
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*Sagittal T1WI MR in a patient with a remote history of pituitary apoplexy caused by Sheehan syndrome shows secondary empty sella <img src='img/arrows/WS.png'/>.*
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**Saccular Aneurysm (Thrombosed)**
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*Axial T1WI C+ FS MR shows pituitary apoplexy mimic. A nonenhancing, cystic-appearing intrasellar mass <img src='img/arrows/WS.png'/> was diagnosed as pituitary apoplexy. Thrombosed ICA aneurysm was found at surgery.*
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**Empty Sella**
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*Sagittal T1WI MR shows empty sella with herniation of CSF through the diaphragma sellae <img src='img/arrows/WS.png'/>, flattening the pituitary gland inferiorly against the sellar floor <img src='img/arrows/WO.png'/>.*
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**Intracranial Hypertension, Idiopathic**
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*Axial T2WI MR shows idiopathic intracranial hypertension (pseudotumor cerebri) with empty sella <img src='img/arrows/WS.png'/> and dilated optic nerve sheaths <img src='img/arrows/WC.png'/>.*
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**Rathke Cleft Cyst**
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*Coronal T1WI MR shows an intrasellar Rathke cleft cyst <img src='img/arrows/WS.png'/>, seen here as a CSF-like mass that displaces the pituitary gland inferiorly and laterally around it.*
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**Neurocysticercosis Cyst**
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*Sagittal T1WI C+ MR shows suprasellar racemose neurocysticercosis (NCC) cysts <img src='img/arrows/WC.png'/> extending into sella turcica <img src='img/arrows/WO.png'/>, flattening pituitary gland against sellar floor <img src='img/arrows/BS.png'/>.*
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**Neurocysticercosis Cyst**
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*Axial T2WI MR shows racemose (multilobulated, grape-like) NCC cysts extending into the suprasellar cistern <img src='img/arrows/CO.png'/> and the cerebellopontine angles <img src='img/arrows/CS.png'/>. Racemose NCC typically involves the basal cisterns and lacks a typical scolex.*
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**Craniopharyngioma**
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*Coronal T2WI MR shows a CSF-like intrasellar mass <img src='img/arrows/BO.png'/>. Surgery disclosed intrasellar craniopharyngioma with only a small suprasellar component. The vast majority of craniopharyngiomas are sellar and suprasellar. Only 5% of craniopharyngiomas are intrasellar.*
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**Arachnoid Cyst**
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*Sagittal T1WI MR shows an intra- and suprasellar arachnoid cyst <img src='img/arrows/WS.png'/>. The lesion did not restrict on DWI, differentiating it from epidermoid cyst.*
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**Epidermoid Cyst**
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*Axial T2WI MR shows a large epidermoid cyst extending into the sella and suprasellar subarachnoid space <img src='img/arrows/WC.png'/> from the quadrigeminal and ambient cisterns <img src='img/arrows/WS.png'/>.*
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