335 lines
30 KiB
Markdown
335 lines
30 KiB
Markdown
---
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title: "Sellar/Juxtasellar Calcification"
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docid: "abd4d403-1196-4957-a168-e0c5507b1008"
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authors:
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- key: "e0282a62-994d-4550-a127-1eb773b1e920"
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value: "Blair A. Winegar, MD"
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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: "Sellar/Juxtasellar Calcification"
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slug: "sellarjuxtasellar-calcification"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "4b6bda02-c315-405d-b4ce-d111c165a64c"
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imageCount: 29
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lastUpdated: "02/01/23"
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pageDescription: "Sellar/Juxtasellar Calcification"
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pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Sellar/Juxtasellar Calcification"
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pageTitle: "Sellar/Juxtasellar Calcification | STATdx"
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enhancedTitle: "Sellar/Juxtasellar Calcification"
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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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- "Sellar/Juxtasellar Calcification"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Is patient asymptomatic?
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- Is calcification physiologic or pathologic?
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- Physiologic
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- Vascular: Age-related changes of atherosclerotic vascular disease (ASVD) common
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- Dural: Petroclinoid ligament often calcified
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- Pathologic
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- Look for associated mass in/around sella, cavernous sinus
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- Anatomic sublocation important
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- Dura (cavernous sinus, tentorium, petroclinoid ligaments) calcifies but less often than falx
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- Arteries, cavernous, and suparclinoid internal carotid artery (ICA) Ca⁺⁺ common
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- Pituitary, infundibulum, hypothalamus almost never show physiologic Ca⁺⁺
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- ## Helpful Clues for Common Diagnoses
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- **Vascular Calcification**
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- Juxtasellar dura, vessels, not brain
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- **Atherosclerosis, Intracranial**
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- Some age-related ASVD Ca⁺⁺ normal, physiologic
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- Strong relationship between carotid stenosis and stroke risk (NASCET criteria)
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- Thickness of Ca⁺⁺ plaque does not correlate directly with luminal stenosis
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- Dense, globular Ca⁺⁺ may be more significant than mural/laminar
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- Some authors suggest high grade of cavernous ICA Ca⁺⁺ correlates with small (not large) vessel ischemia
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- Carotid intraplaque hemorrhage is independent risk factor for acute stroke
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- **Saccular Aneurysm**
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- Supra-/juxtasellar > intracavernous
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- Mural Ca⁺⁺ common
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- Ca⁺⁺ may be rim or globular
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- Aneurysm often partially/completely thrombosed
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- CTA/MRA key for accurate diagnosis
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- Pulsation artifact may be seen on MR
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- **Meningioma**
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- Ca⁺⁺ in 20-25%; pattern highly variable
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- Diffuse or focal
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- Solid (brain rock) or scattered
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- Psammomatous (sand-like) or sunburst > globular > rim
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- Look for dural tail
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- Look for changes in adjacent planum sphenoidale and clinoid processes (hyperostosis)
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- Can cause blistering, hyperostosis, hypertrophied ethmoid or sphenoid sinuses (pneumosinus dilatans)
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- **Craniopharyngioma**
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- Adamantinomatous craniopharyngioma
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- 90% cystic, 90% Ca⁺⁺ (rim, globular), 90% enhance
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- Bimodal age distribution: 5-15 years and 45-60 years
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- Papillary craniopharyngioma
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- Solid mass with variable globular Ca⁺⁺, enhancement
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- Typically adults
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- **Neurocysticercosis**
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- Healed racemose neurocysticercosis (NCC) in basal cisterns may show Ca⁺⁺
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- Cisternal NCC, often racemose (lobulated, grape-like), lacking scolex
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- Typically occurs in high convexity subarachnoid spaces
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- May involve cisterns > parenchyma > ventricles
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- ## Helpful Clues for Less Common Diagnoses
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- **Dermoid Cyst**
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- Sellar/parasellar/frontonasal region most common site
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- Unilocular fat-like cyst
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- Look for "droplets" in sulci, cisterns (ruptured dermoid)
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- 20% have capsular Ca⁺⁺
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- **Astrocytoma**
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- **Pilocytic a****strocytoma**
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- Common in optic chiasm/hypothalamus/3rd ventricle (2nd most common location after cerebellum)
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- Enhancement varies (none to striking)
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- Ca⁺⁺ uncommon in supratentorial pilocytic astrocytomas
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- WHO grade 1
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- **Pilomyxoid astrocytoma**
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- Rare tumor; commonly hypothalamic/chiasmatic region
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- Hemorrhage common
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- Affects infants and young children
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- Ca⁺⁺ uncommon
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- **Astrocytoma, IDH-mutant**
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- May calcify but uncommon in this location
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- T2 hyperintense
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- No enhancement
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- WHO grades 2-4
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- **Chordoid glioma**
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- WHO grade 2, rare tumor
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- Hypothalamus/anterior 3rd ventricle mass
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- Ovoid, well circumscribed
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- Usually solid mass; may have associated cysts (rare)
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- Hyperdense on NECT; Ca⁺⁺ variable
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- Isointense on T1-, iso- to mildly hyperintense on T2WI
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- Enhances strongly, usually uniformly
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- **Arteriovenous Malformation**
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- Supra-/juxtasellar < hemispheres
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- 25-30% have Ca⁺⁺
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- Pial vascular malformation of brain
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- Artery to vein shunting without intervening capillary bed
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- MR: Tangle or serpiginous flow voids, "bag of worms"
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- ## Helpful Clues for Rare Diagnoses
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- **Cavernous Malformation**
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- Ca⁺⁺ common; popcorn or mulberry appearance
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- Cerebral hemispheres most common location
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- Hypothalamus, juxtasellar lesions uncommon
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- May be associated with adjacent developmental venous anomaly
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- Contains masses of closely apposed immature blood vessels
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- **Chondrosarcoma, Skull Base**
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- Center at petrooccipital fissure
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- 50% have chondroid Ca⁺⁺ in tumor matrix (arcs, rings)
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- T2 hyperintense, high ADC value (≥ 2.0 x 10⁻³ mm²/sec)
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- Enhance strongly, heterogeneously
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- Whorls of enhancing lines within tumor matrix
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- **Chordoma, Clivus**
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- 35% arise in skull base
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- Center at sphenooccipital synchondrosis
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- Destructive, invasive clivus mass
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- CT: 50% contain ossific fragments of destroyed bone
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- T2 hyperintense; heterogeneous enhancement
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- **Pituitary Macroadenoma**
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- Most common lesion in this location
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- Only 1-2% Ca⁺⁺
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- Can be very invasive, destructive
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- **Rathke Cleft Cyst**
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- Only 10-15% Ca⁺⁺ vs. > 90% of craniopharyngioma
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- Calcified Rathke cleft cyst may be indistinguishable from craniopharyngioma
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- No enhancement of cyst
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- Normal pituitary often wraps around cyst: Claw sign
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- **Benign Nonmeningothelial Tumors**
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- Rare cause of juxtasellar Ca⁺⁺
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- **Chondroma**: Occurs along sella/parasellar most common; dura/falx rare
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- Expansile, lobulated soft tissue mass
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- Curvilinear matrix Ca⁺⁺
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- **Osteochondroma**: Usually arises from skull base; dura/falx rare
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- May see Ca⁺⁺ matrix in cap atop cortical bone
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- Parent bone contiguous with cortex of osteochondroma
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- **Osteoma**: Usually arises from outer table of calvarium, rarely inner table
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- Dense lesion without diploic involvement
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- **Osteosarcoma, Skull Base**
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- Osteolytic or blastic lesions with soft tissue mass and ill-defined margins
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- Tumor Ca⁺⁺ may be sunburst
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- Heterogeneous enhancement
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## References
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# Selected References
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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. [Muneer MS et al: Chordoid glioma: a rare old foe but a new pathological and radiological presentation. Clin Imaging. 78:160-4, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33836423%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. [Chapman PR et al: Neuroimaging of the pituitary gland: practical anatomy and pathology. Radiol Clin North Am. 58(6):1115-33, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33040852%5Bpmid%5D)
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1. [Khan Y et al: Pituitary Adenoma with Calcifications: A Case Report. Cureus. 11(8):e5542, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31687314%5Bpmid%5D)
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1. [Jacków J et al: Ruptured intracranial dermoid cysts: a pictorial review. Pol J Radiol. 83:e465-e470, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30655926%5Bpmid%5D)
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1. [McNally JS et al: Magnetic resonance imaging detection of intraplaque hemorrhage. Magn Reson Insights. 10:1-8, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28469441%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. [Starc MT et al: Rare presentation of Ewing sarcoma metastasis to the sella and suprasellar cistern. Clin Imaging. 41:73-77, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27816880%5Bpmid%5D)
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1. [Teng Z et al: Carotid intraplaque hemorrhage: a biomarker for subsequent ischemic cerebrovascular event. Cerebrovasc Dis. 43(5-6):257-258, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28259890%5Bpmid%5D)
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1. [Hayashi Y et al: Pediatric symptomatic Rathke cleft cyst compared with cystic craniopharyngioma. Childs Nerv Syst. 32(9):1625-32, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27392448%5Bpmid%5D)
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1. [Hoffmann A et al: Fusiform dilatation of the internal carotid artery in childhood-onset craniopharyngioma: multicenter study on incidence and long-term outcome. Pituitary. 19(4):422-8, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27125511%5Bpmid%5D)
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1. [Sekiguchi K et al: Osteochondroma Presenting as a Calcified Mass in the Sellar Region and Review of the Literature. J Neurol Surg A Cent Eur Neurosurg. ePub, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27903019%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. [Yeom KW et al: Diffusion-weighted MRI: distinction of skull base chordoma from chondrosarcoma. AJNR Am J Neuroradiol. 34(5):1056-61, S1, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23124635%5Bpmid%5D)
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1. [Hanak BW et al: Cerebral aneurysms with intrasellar extension: a systematic review of clinical, anatomical, and treatment characteristics. J Neurosurg. 116(1):164-78, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22054212%5Bpmid%5D)
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## Images
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### Selected Images
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**Physiologic Calcification, Dura**
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*Axial NECT bone window shows dural calcifications <img src='img/arrows/CS.png'/> along the petroclinoid ligaments. Although typically physiologic, multiple dural calcifications may also be seen in basal cell nevus syndrome.*
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**Physiologic Calcification, Dura**
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*Axial NECT bone window shows dural calcifications <img src='img/arrows/CS.png'/> along the petroclinoid ligaments. Although typically physiologic, multiple dural calcifications may also be seen in basal cell nevus syndrome.*
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**Atherosclerosis, Intracranial**
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*Coronal NECT shows atherosclerotic calcifications along the walls of the bilateral intracranial ICAs <img src='img/arrows/CS.png'/> and left MCA <img src='img/arrows/CO.png'/>. Intracranial atherosclerosis often involves the intracranial internal carotid and vertebral arteries. There is often mural calcification and decreased vessel caliber.*
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**Saccular Aneurysm**
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*Axial NECT shows scattered subarachnoid hemorrhage <img src='img/arrows/WS.png'/> within the interhemispheric and sylvian fissures. A rounded hypodense lesion <img src='img/arrows/CO.png'/> with peripheral calcification <img src='img/arrows/CC.png'/> in the left suprasellar cistern is the causative ruptured saccular ICA aneurysm.*
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**Meningioma**
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*Axial CECT shows an extensive plaque-like calcification along the optic nerve sheath <img src='img/arrows/WS.png'/> and left anterolateral cavernous sinus <img src='img/arrows/WO.png'/> related to a meningioma. Strong, homogeneous enhancement is typical following contrast administration.*
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**Craniopharyngioma**
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*Coronal NECT shows a complex cystic/solid mass <img src='img/arrows/CS.png'/> with internal hemorrhage <img src='img/arrows/CO.png'/> and calcifications <img src='img/arrows/CC.png'/> in the sella and suprasellar regions related to craniopharyngioma. This mass results in obstructive hydrocephalus <img src='img/arrows/WS.png'/>.*
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**Dermoid Cyst**
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*Coronal NECT shows a complex cystic sellar/parasellar mass with internal fat and peripheral calcification <img src='img/arrows/CO.png'/> compatible with a dermoid cyst. Fat within the subarachnoid spaces <img src='img/arrows/CC.png'/> are related to prior rupture, which may result in a chemical meningitis.*
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**Pilomyxoid Astrocytoma**
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*Axial NECT shows calcification <img src='img/arrows/WS.png'/> in a hypothalamic/suprasellar mass in a 12-year-old child. A pilomyxoid subtype of pilocytic astrocytoma was diagnosed at surgery. These rare tumors often occur in the hypothalamic region.*
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**Chordoid Glioma**
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*Axial NECT in this 48-year-old with progressive visual decline shows a hyperdense suprasellar mass <img src='img/arrows/CS.png'/> with globular calcifications <img src='img/arrows/CO.png'/>. Preoperative diagnosis was papillary craniopharyngioma. Chordoid glioma was diagnosed at surgery.*
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**Arteriovenous Malformation**
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*Axial NECT shows a slightly hyperdense <img src='img/arrows/WS.png'/> calcified <img src='img/arrows/WO.png'/> mass in the right medial temporal lobe. CECT scans showed typical findings of arteriovenous malformation.*
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**Cavernous Malformation**
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*Axial NECT shows a very large, partially calcified mass <img src='img/arrows/BS.png'/> extending inferiorly from the ventricles into the hypothalamus. Cavernous malformations are benign vascular hamartomas that most commonly occur in the hemispheres.*
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**Chondrosarcoma, Skull Base**
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*Axial NECT bone window shows a destructive central skull base mass <img src='img/arrows/CS.png'/> with internal chondroid matrix <img src='img/arrows/CC.png'/> in this case of chondrosarcoma. These masses typically arise from the petrooccipital fissure.*
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**Chordoma, Clivus**
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*Sagittal CECT shows a destructive lesion of the central skull base <img src='img/arrows/CS.png'/> with rim calcification <img src='img/arrows/CO.png'/> and fragments of residual bone. There is significant associated mass effect on the brainstem <img src='img/arrows/BO.png'/>, typical of clival chordomas. These malignant tumors have a high recurrence rate.*
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**Pituitary Macroadenoma**
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*Axial NECT shows a large, lobulated, hyperdense suprasellar mass <img src='img/arrows/CS.png'/>. This invasive macroadenoma extended into the posterior paranasal sinuses and along the anterior pons <img src='img/arrows/WS.png'/> with focal calcification <img src='img/arrows/WO.png'/>. Only 1-2% of macroadenomas calcify.*
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**Chondroma**
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*Coronal CECT shows an intrasellar mass with dense globular calcification <img src='img/arrows/WS.png'/>, typical of benign chondroma. No stalk was found connecting the chondroma to parent bone. (Courtesy L. Cromwell, MD.)*
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### Additional Images
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**Meningioma**
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*Axial NECT shows marked hyperostosis of the anterior clinoid process <img src='img/arrows/CS.png'/> and the posterior clinoid process <img src='img/arrows/CO.png'/> related to a suprasellar meningioma. These WHO grade I tumors are very common in the parasellar region and may mimic a pituitary adenoma.*
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**Dermoid Cyst**
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*Axial NECT shows a mass with fat-debris level <img src='img/arrows/WO.png'/> extending from the suprasellar cistern into the sylvian fissure. Note calcification <img src='img/arrows/WC.png'/> and fat droplets in CSF <img src='img/arrows/WS.png'/> from a ruptured dermoid.*
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**Physiologic Calcification, Dura**
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*Axial bone CT shows physiologic calcification in both cavernous internal carotid arteries <img src='img/arrows/BS.png'/> as well as the dura of the cavernous sinus wall <img src='img/arrows/WS.png'/> and both petroclinoid ligaments <img src='img/arrows/WO.png'/>.*
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**Saccular Aneurysm**
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*Axial NECT shows a subarachnoid hemorrhage <img src='img/arrows/WO.png'/> from a partially thrombosed, calcified <img src='img/arrows/WS.png'/> basilar tip aneurysm.*
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**Chondrosarcoma, Skull Base**
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*Axial bone CT shows a large partially calcified mass <img src='img/arrows/WS.png'/> extending from the skull base into the sella, causing obstruction of the sphenoid sinus <img src='img/arrows/WO.png'/>.*
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**Osteochondroma**
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*Sagittal bone CT reconstructed from axial data shows globular intra- and suprasellar calcification <img src='img/arrows/WS.png'/> in cartilaginous cap of an osteochondroma arising from cortex of dorsum sellae <img src='img/arrows/BC.png'/>.*
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**Osteochondroma**
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*Axial T2WI MR in same case as prior CT shows very hypointense mass <img src='img/arrows/WC.png'/> above dorsum sellae. NECT scan showed dense calcifications within a tumor cap characteristic for osteochondroma.*
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**Craniopharyngioma**
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*Axial NECT shows rim <img src='img/arrows/WS.png'/> and globular <img src='img/arrows/WC.png'/> calcification in a multicystic suprasellar mass in child. Note fluid-fluid level <img src='img/arrows/WO.png'/>. Most calcified suprasellar masses in children are craniopharyngiomas.*
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**Neurocysticercosis**
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*Axial NECT shows punctate Ca⁺⁺ <img src='img/arrows/WS.png'/> in the suprasellar and ambient cisterns from chronic racemose cysticercosis. (Courtesy E. Bravo, MD.)*
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**Pituitary Macroadenoma**
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*Coronal CECT shows a large, lobulated, calcified <img src='img/arrows/BS.png'/>, intra- and suprasellar mass that encases the right internal carotid artery <img src='img/arrows/BO.png'/>. Only 1-2% of macroadenomas calcify.*
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**Chordoid Glioma**
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*Axial NECT in this 48 year old with progressive visual decline shows hyperdense suprasellar mass with globular calcifications <img src='img/arrows/WS.png'/>. Pre-operative diagnosis was papillary subtype of craniopharyngioma. Chordoid glioma of 3rd ventricle was found at surgery.*
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**Chordoma, Clivus**
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*Axial CECT shows destructive lesion of central skull base encasing both internal carotid arteries and containing flecks of residual bone or calcifications <img src='img/arrows/WO.png'/>.*
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**Atherosclerosis, Intracranial**
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*Axial NECT shows prominent calcific changes in both supraclinoid internal carotid arteries <img src='img/arrows/CS.png'/> caused by atherosclerosis. Intracranial atherosclerosis often involves the distal basilar artery and the cavernous and supraclinoid internal carotid arteries. There is often mural calcification and decreased vessel caliber.*
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**Saccular Aneurysm**
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*Axial CECT shows a giant, mostly thrombosed, saccular aneurysm. Note the ring enhancement <img src='img/arrows/CO.png'/> of the thrombosed segment of the aneurysm as well as globular <img src='img/arrows/CS.png'/> and rim <img src='img/arrows/CC.png'/> calcification. CTA or MRA is key for making an accurate preoperative diagnosis.*
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**Craniopharyngioma**
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*Axial NECT shows rim <img src='img/arrows/CS.png'/> and globular <img src='img/arrows/CO.png'/> calcification in a cystic suprasellar mass in a 7-year-old child. Most calcified suprasellar masses in children are craniopharyngiomas. This craniopharyngioma also showed enhancement on postcontrast images.*
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