226 lines
21 KiB
Markdown
226 lines
21 KiB
Markdown
---
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title: "Enhancing Suprasellar Mass"
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docid: "528eaea9-095f-4fab-ad42-5ad84e215a2d"
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authors:
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- key: "318f80ab-6abb-4067-a809-2ebdaa5a30c9"
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value: "Kalen Riley, MD, MBA"
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- key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
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value: "Anne G. Osborn, MD, FACR"
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- key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
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value: "Karen L. Salzman, 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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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: "Enhancing Suprasellar Mass"
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slug: "enhancing-suprasellar-mass"
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treeNodeId: null
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category: "Brain"
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cmeTopicId: "01b1cc14-8442-4bbd-93ff-bd8895b90f87"
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documentVersionId: "39bca65a-aa9f-4818-9b63-d727551a81f1"
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imageCount: 19
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lastUpdated: "01/26/23"
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pageDescription: "Enhancing Suprasellar Mass"
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pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Enhancing Suprasellar Mass"
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pageTitle: "Enhancing Suprasellar Mass | STATdx"
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enhancedTitle: "Enhancing Suprasellar 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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- "Enhancing Suprasellar Mass"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Effect of age on differential diagnosis important
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- Common lesions ("big 5") account for > 75% of all suprasellar masses
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- Most other lesions < 1-2% each
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- Differential diagnosis narrows if mass confined to infundibulum
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- ## Helpful Clues for Common Diagnoses
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- **Pituitary Macroadenoma vs. Meningioma**
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- Macroadenoma: Gland cannot be identified separate from mass
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- Meningioma: Mass distinct from gland (diaphragma sellae separates mass above from pituitary below)
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- **S****accular****Aneurysm**
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- Coronal plane helps distinguish aneurysm from pituitary
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- Look for phase artifact, flow void on MR
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- **Craniopharyngioma**
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- Adamantinomatous: 90% Ca⁺⁺, 90% cystic, 90% enhance
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- Papillary may be solid, noncalcified, enhance strongly
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- **Pilocytic Astrocytoma**
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- More common in children than adults
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- T2 hyperintense, variable enhancement
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- Expands hypothalamus, optic chiasm
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- May extend into optic nerves/tracts
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- **Pilomyxoid Astrocytoma**
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- Subtype of pilocytic astrocytoma, more aggressive
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- Infant > child
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- Large, bulky tumor with lateral extension to temporal lobe common
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- Hemorrhage in 20-25%
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- ## Helpful Clues for Less Common Diagnoses
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- **Pituitary Hyperplasia**
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- May be physiologic (pregnancy, lactation, puberty)
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- Pathologic in end-organ failure (thyroid, ovarian, etc.)
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- **Neurosarcoid**
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- Older patients, enhancing mass
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- **Langerhans Cell Histiocytosis**
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- Children and young adults; enhancing mass
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- May cause thickened infundibulum
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- Absence of pituitary "bright spot"
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- **Germinoma**
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- Children > > adults; enhancing mass
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- CT hyperdense
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- May cause thickened infundibulum
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- Absence of the pituitary "bright spot"
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- **Lymphocytic Hypophysitis**
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- Can mimic pituitary adenoma on imaging
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- Most common in peripartum female
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- May be autoimmune, inflammatory, granulomatous process, drug related
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- May be secondary to checkpoint inhibitor therapy
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- **Astrocytoma, IDH-Mutant**
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- May affect hypothalamic and suprasellar regions
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- T2 hyperintense; variable enhancement
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- WHO grades 2-4
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- ## Helpful Clues for Rare Diagnoses
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- Solitary**metastasis** to gland &/or stalk rare
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- **Lymphoma**, **leukemia** usually with systemic disease
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- **Pituicytoma, g****ranular cell tumor**, and **spindle cell oncocytoma** are rare tumors, which may occur along infundibulum &/or posterior pituitary or may mimic macroadenoma
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- ## Alternative Differential Approaches
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- **Adult**: Consider adenoma, meningioma, and aneurysm
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- **Child**: Craniopharyngioma, astrocytoma, Langerhans cell histiocytosis, and germinoma
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## References
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# Selected References
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1. [Kinoshita Y et al: Natural course of Rathke's cleft cysts and risk factors for progression. J Neurosurg. 1-7, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36057119%5Bpmid%5D)
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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)
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1. [Poyuran R et al: Nonneoplastic and noninfective cysts of the central nervous system: a histopathological study. Neuropathology. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36210745%5Bpmid%5D)
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1. [Jipa A et al: Imaging of the sellar and parasellar regions. Clin Imaging. 77:254-75, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34153590%5Bpmid%5D)
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1. [Kurokawa R et al: MRI findings of immune checkpoint inhibitor-induced hypophysitis: possible association with fibrosis. AJNR Am J Neuroradiol. 41(9):1683-9, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32763900%5Bpmid%5D)
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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)
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1. [Seeburg DP et al: Imaging of the sella and parasellar region in the pediatric population. Neuroimaging Clin N Am. 27(1):99-121, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27889026%5Bpmid%5D)
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1. [Zamora C et al: Sellar and parasellar imaging. Neurosurgery. 80(1):17-38, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28362892%5Bpmid%5D)
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1. [Patel KS et al: Intraoperative magnetic resonance imaging assessment of non-functioning pituitary adenomas during transsphenoidal surgery. Pituitary. 19(2):222-31, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26323592%5Bpmid%5D)
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1. [Petrakakis I et al: The sellar and suprasellar region: a "hideaway" of rare lesions. Clinical aspects, imaging findings, surgical outcome and comparative analysis. Clin Neurol Neurosurg. 149:154-65, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27540757%5Bpmid%5D)
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1. [Wang J et al: The clinicopathological features of pituicytoma and the differential diagnosis of sellar glioma. Neuropathology. 36(5):432-440, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26919073%5Bpmid%5D)
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1. [Wu AW et al: Chondroid chordoma of the sella turcica mimicking a pituitary adenoma. Ear Nose Throat J. 94(10-11):E47-9, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26535833%5Bpmid%5D)
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1. DW Louis, et. al (Editors). WHO Classification of Tumours of the Central Nervous System. International Agency for Research on Cancer, Lyon, 2016. Chapter 17: Tumours of the sellar region, pp 323-334.
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## Images
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### Selected Images
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**Pituitary Macroadenoma**
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*Coronal T1 C+ MR shows an enhancing intrasellar and suprasellar mass <img src='img/arrows/CS.png'/>. The pituitary gland cannot be separated from the mass and indeed is the mass. Note the superior displacement of the optic chiasm <img src='img/arrows/WS.png'/> by the macroadenoma.*
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**Pituitary Macroadenoma**
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*Coronal T1 C+ MR shows an enhancing intrasellar and suprasellar mass <img src='img/arrows/CS.png'/>. The pituitary gland cannot be separated from the mass and indeed is the mass. Note the superior displacement of the optic chiasm <img src='img/arrows/WS.png'/> by the macroadenoma.*
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**Meningioma**
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*Coronal T1 C+ FS MR shows a suprasellar enhancing mass <img src='img/arrows/CO.png'/> separate from the normal pituitary gland below <img src='img/arrows/WC.png'/>. Meningiomas often have associated hyperostosis of the adjacent bone. Additionally, these benign tumors enhance homogeneously and may have an associated dural tail.*
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**Saccular Aneurysm**
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*Axial T1 C+ MR shows a suprasellar enhancing mass <img src='img/arrows/WS.png'/> with prominent phase artifact <img src='img/arrows/WO.png'/> caused by large basilar tip aneurysm with slow intraluminal flow. Aneurysms are the 3rd most common suprasellar mass in an adult.*
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**Craniopharyngioma**
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*Sagittal T1 C+ MR shows an enhancing, partially solid and cystic suprasellar mass <img src='img/arrows/WS.png'/> related to an adamantinomatous craniopharyngioma. These WHO grade 1 tumors are the most common pediatric intracranial tumor of nonglial origin.*
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**Pilomyxoid Astrocytoma**
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*Coronal T1 C+ FS MR shows a heterogeneously enhancing suprasellar mass <img src='img/arrows/CO.png'/> in a child that was found to represent a pilomyxoid astrocytoma, WHO grade 1. Pilomyxoid astrocytoma is a subtype of pilocytic astrocytoma that is often more aggressive.*
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**Neurosarcoid**
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*Axial T1 C+ FS MR shows a lobular, enhancing suprasellar mass <img src='img/arrows/CO.png'/> related to neurosarcoid. Patients with neurosarcoid often have associated pulmonary hilar adenopathy.*
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**Langerhans Cell Histiocytosis**
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*Axial T1 C+ FS MR shows a diffusely enhancing suprasellar mass <img src='img/arrows/CO.png'/> in a young adult who first presented with diabetes insipidus and a thick, enhancing infundibulum with absence of a posterior pituitary bright spot. Nine months later, patient returned with a much larger suprasellar mass.*
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**Lymphocytic Hypophysitis**
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*Coronal T2 MR in a pregnant patient with acute vision problems shows a sellar and suprasellar mass <img src='img/arrows/CO.png'/> with superior displacement of the optic chiasm <img src='img/arrows/CS.png'/>. Imaging of lymphocytic hypophysitis may mimic a pituitary macroadenoma.*
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### Additional Images
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**Pituitary Macroadenoma**
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*Coronal T1 C+ MR shows an inhomogeneously enhancing intra- and suprasellar mass <img src='img/arrows/WS.png'/>; the pituitary gland cannot be found separate from it and indeed is the mass.*
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**Meningioma**
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*Coronal T1 C+ FS MR shows a suprasellar enhancing mass <img src='img/arrows/WO.png'/> separated from the normal pituitary gland below <img src='img/arrows/WC.png'/> by a thin black line of diaphragma sellae <img src='img/arrows/WS.png'/>.*
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**Craniopharyngioma**
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*Coronal T1 C+ MR in a child shows a intra-/suprasellar mass. An apical nonenhancing portion is surrounded by a thin enhancing rim <img src='img/arrows/WC.png'/>. The solid portion enhances strongly but heterogeneously <img src='img/arrows/WS.png'/>.*
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**Craniopharyngioma**
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*Sagittal T1 C+ FS MR shows a papillary craniopharyngioma in an adult man. Papillary craniopharyngiomas are most often solid masses.*
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**Astrocytoma, IDH-Mutant**
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*Coronal T1 C+ MR shows an enhancing suprasellar mass <img src='img/arrows/WS.png'/> separate from the pituitary gland below <img src='img/arrows/WO.png'/>. Note involvement of the optic chiasm <img src='img/arrows/WC.png'/>.*
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**Pilocytic Astrocytoma**
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*Sagittal T1 C+ MR in a 3-year-old boy with rotary nystagmus and vomiting shows a large suprasellar mass <img src='img/arrows/WS.png'/> clearly separate from the pituitary gland below <img src='img/arrows/BO.png'/>.*
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**Neurosarcoid**
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*Axial T1 C+ FS MR shows an enhancing suprasellar mass involving the optic chiasm <img src='img/arrows/WS.png'/> and hypothalamus <img src='img/arrows/WO.png'/> with pial enhancement along the inferior frontal lobe <img src='img/arrows/WC.png'/>. The lesion also involved the optic nerve.*
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**Germinoma**
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*Coronal T1 C+ FS MR in 22-year-old man with diabetes insipidus shows hydrocephalus and an enhancing sellar/suprasellar mass. Germinoma commonly presents with diabetes insipidus. A macroadenoma often has visual defects.*
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**Rare Sellar Region Tumor (Pituicytoma, Granular Cell Tumor, Spindle Cell Oncocytoma)**
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*Coronal T1 C+ MR shows a diffusely enhancing suprasellar mass <img src='img/arrows/CO.png'/> that involves the infundibulum. A pituicytoma was diagnosed at resection. These rare tumors are WHO grade 1 and usually arise along the infundibulum or neurohypophysis. (Courtesy A.V. Hasso, MD.)*
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**Craniopharyngioma**
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*Axial T1 C+ FS MR shows a cystic and solid suprasellar enhancing mass <img src='img/arrows/CS.png'/>. In an adult, craniopharyngiomas may be adamantinomatous or papillary types. Adamantinomatous craniopharyngiomas enhance, calcify, and have cysts. Papillary craniopharyngiomas are commonly solid and enhancing. These are WHO grade 1 tumors.*
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**Pilocytic Astrocytoma**
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*Coronal T1 C+ FS MR in 25-year-old woman with visual complaints shows an enhancing suprasellar mass <img src='img/arrows/WS.png'/> that partially encases the optic chiasm <img src='img/arrows/WC.png'/>. There is also a parasellar cystic portion <img src='img/arrows/WO.png'/> of the mass. Pilocytic astrocytomas often present as a solid and cystic cerebellar mass in a child or young adult. These WHO grade 1 tumors are typically T2 hyperintense with variable enhancement.*
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