statdx/docs_md/articles/intrasellar-lesion_391834ff-565f-401b-bfbd-0bc40f6b83bf.md

title, docid, authors, breadcrumbs, category, documentVersionId, imageCount, lastUpdated, pageDescription, pageKeywords, pageTitle, enhancedTitle, type, references, breadcrumbs

title	docid	authors	breadcrumbs	category	documentVersionId	imageCount	lastUpdated	pageDescription	pageKeywords	pageTitle	enhancedTitle	type	references	breadcrumbs
Intrasellar Lesion	391834ff-565f-401b-bfbd-0bc40f6b83bf	key value e0282a62-994d-4550-a127-1eb773b1e920 Blair A. Winegar, MD key value 8d5254e9-8dda-478b-8f08-bdee97a32c79 Karen L. Salzman, MD, FACR key value 5cff4116-3654-4b3a-bb75-5ebe0b8c9850 Anne G. Osborn, MD, FACR	name slug treeNodeId Brain brain 6d8829f1-14d7-45af-8675-255189aa526a name slug treeNodeId Differential Diagnosis differential-diagnosis a7fdd139-664e-4bb8-8d18-400e4733ff60 name slug treeNodeId Sella/Juxtasellar, Pineal Region sellajuxtasellar-pineal-region 5e38b9c1-3137-47e3-aa83-1fc82cb4099a name slug treeNodeId Anatomically Based Differentials anatomically-based-differentials 7a51b2ca-8fee-4c16-aff3-b7189f68ea60 name slug treeNodeId Intrasellar Lesion intrasellar-lesion null	Brain	216cd491-5de9-461c-8fdd-c0c0580f06de	21	03/15/23	Intrasellar Lesion	Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Intrasellar Lesion	Intrasellar Lesion | STATdx	Intrasellar Lesion	DDX	true	Brain Differential Diagnosis Sella/Juxtasellar, Pineal Region Anatomically Based Differentials Intrasellar Lesion

---

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
2. 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
3. Yan S et al: Sellar region lesions and intracranial aneurysms in the era of endoscopic endonasal approach. Front Endocrinol (Lausanne). 12:802426, 2021
4. 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
5. 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
6. Go JL et al: Imaging of the sella and parasellar region. Radiol Clin North Am. 55(1):83-101, 2017
7. Sasagawa Y et al: Clinical characteristics of acromegalic patients with empty sella and their outcomes following transsphenoidal surgery. Pituitary. 20(4):403-8, 2017
8. 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

Images

Selected Images

Pituitary Hyperplasia Coronal T1 C+ MR shows marked enlargement of the pituitary gland 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 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 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 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 . 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 within the pituitary gland between the adenohypophysis anteriorly and the neurohypophysis posteriorly 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 in this 32-year-old with mild prolactin elevation. Note the optic chiasm 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 , brainstem slumping , and cerebellar ectopia , consistent with intracranial hypotension.

Lymphoma, Primary CNS Coronal T1 C+ MR shows a mass lesion diffusely infiltrating and expanding the pituitary gland . Note extension into the left cavernous sinus , 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 in this 28-year-old woman with seizures. Note the thinned pituitary gland 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 with a small intracystic nodule . 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 . 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 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 that displaces the pituitary gland . Totally intrasellar craniopharyngioma without suprasellar extension is rare.

Neurosarcoid Coronal T1 C+ MR shows a slightly enlarged pituitary gland with a thickened infundibulum above in a patient with proven neurosarcoidosis.

Intracranial Hypotension Sagittal T1 MR shows the classic "slumping midbrain" with draping of the optic chiasm over an enlarged pituitary gland .

"Kissing" Carotid Arteries Coronal T2 FS MR shows "kissing" (paramedian) cavernous internal carotid arteries 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 and thickened infundibular stalk .

Pituitary Microadenoma Coronal T2 MR shows a hyperintense intrasellar mass . 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 compressing the pituitary gland , 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 caused by iron overload syndrome. A hemorrhagic adenoma could have a similar appearance.*