354 lines
35 KiB
Markdown
354 lines
35 KiB
Markdown
---
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title: "Suprasellar Cystic Mass"
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docid: "4748e65c-f466-495b-bc2c-c4389d55b3ad"
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authors:
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- key: "8bf951c6-3575-4f38-8878-17cd9d4f2d12"
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value: "Tabassum A. Kennedy, 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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- 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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-
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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: "Suprasellar Cystic Mass"
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slug: "suprasellar-cystic-mass"
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treeNodeId: null
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category: "Brain"
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cmeTopicId: "5b0b2112-3a03-4596-ab11-c607ec747ec1"
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documentVersionId: "8694d24d-fa93-4529-89ec-d09e28cfd534"
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imageCount: 34
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lastUpdated: "02/02/23"
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pageDescription: "Suprasellar Cystic Mass"
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pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Suprasellar Cystic Mass"
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pageTitle: "Suprasellar Cystic Mass | STATdx"
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enhancedTitle: "Suprasellar Cystic 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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- "Suprasellar Cystic Mass"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Where does mass originate?
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- 3rd ventricle: Think hydrocephalus > intraventricular cystic mass (ependymal cyst, craniopharyngioma)
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- Suprasellar cistern: Arachnoid, other congenital/infectious cysts
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- Pituitary gland/sella turcica: Necrotic/cystic neoplasm or cyst
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- Brain parenchyma: Enlarged perivascular spaces, cystic/low density neoplasm
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- Hypothalamus/optic nerve: Cystic neoplasm
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- ## Helpful Clues for Common Diagnoses
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- **Enlarged 3rd Ventricle**
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- CSF density/signal intensity
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- No enhancement (unless infection, neoplasm)
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- **Obstructive hydrocephalus**
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- Can be intra- or extraventricular (noncommunicating or communicating)
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- If acute, periventricular "halo" of transependymal CSF flow
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- "Cystic mass" = dilated 3rd ventricle
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- **Aqueductal stenosis**
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- ↑ lateral, 3rd ventricles
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- Normal 4th ventricle
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- Usually longstanding, "compensated" so no transependymal CSF
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- **Arachnoid Cyst**
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- 10% of arachnoid cysts (ACs) suprasellar
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- Sharply marginated CSF density/signal intensity mass
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- Complete suppression on FLAIR
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- Does not restrict on DWI
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- 3rd ventricle elevated, displaced over AC
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- Displaces temporal lobes laterally
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- Displaces midbrain, pons posteriorly
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- Infundibular stalk typically displaced anteriorly
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- "Mickey mouse ears" on coronal = cyst + lateral ventricles
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- If large, may also cause obstructive hydrocephalus
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- **Craniopharyngioma**
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- Adamantinomatous: 90% of childhood craniopharyngiomas cystic
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- Cyst fluid hyperdense/intense to CSF
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- 90% have some Ca⁺⁺ (globular or rim)
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- 90% enhance (rim, nodular)
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- Suprasellar cistern > > **within** 3rd ventricle
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- **Neurocysticercosis**
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- Look for "clusters" of cysts in subarachnoid cisterns [racemose neurocysticercosis (NCC)]
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- Look for cyst + scolex
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- FLAIR best sequence to detect racemose NCC (cyst fluid does not suppress completely)
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- Scolex: T2 hypointense, DWI hyperintense
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- ## Helpful Clues for Less Common Diagnoses
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- **Rathke Cleft Cyst**
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- 60% purely suprasellar or intrasellar with suprasellar extension
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- Variable density/signal intensity
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- Usually ↑ compared to CSF
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- Up to 10% calcify (curvilinear, in cyst wall)
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- No enhancement following contrast
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- Look for
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- Intracystic nodule (45-75%)
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- "Claw" of compressed, enhancing pituitary displaced around cyst
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- **Pituitary Macroadenoma**
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- Solid ± intra- or extratumoral cysts common
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- Extratumoral cysts may be trapped/enlarged perivascular spaces or ACs
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- Cysts often hyperdense/intense compared to CSF
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- Solid > rim enhancement
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- Occasionally mostly cystic mass
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- **Dermoid Cyst**
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- Most common site = sellar/parasellar, frontonasal
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- Fat density/signal intensity
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- 20% have capsular Ca⁺⁺
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- Look for evidence of rupture
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- Fat droplets in subarachnoid spaces
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- Fat-fluid levels in ventricles
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- Chemical shift artifact in frequency encoding direction
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- **Epidermoid Cyst**
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- Rare in suprasellar cistern
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- Lobulated, insinuating growth pattern
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- > 95% hypodense (similar to CSF)
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- FLAIR, DWI best to distinguish epidermoid from arachnoid cyst, enlarged 3rd ventricle
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- Epidermoid does not suppress completely on FLAIR, restricts on DWI
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- **Enlarged Perivascular Spaces**
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- Usually variable-sized "clusters"
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- Off-midline (basal ganglia)
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- Round or ovoid (basal ganglia), linear (white matter)
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- Like CSF on all sequences (contain interstitial fluid)
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- Suppresses completely on FLAIR
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- Does not restrict on DWI
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- ## Helpful Clues for Rare Diagnoses
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- **Pituitary Apoplexy**
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- Rare; may be life-threatening (severe panhypopituitarism)
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- Necrotic pituitary with little/no enhancement (may show rim)
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- Hemorrhage may bloom on T2* (GRE, SWI)
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- Compression/edema of hypothalamus, optic chiasm/tracts may cause hyperintensity on T2WI
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- May show DWI restriction, hypointense on ADC
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- Rarely associated with subarachnoid hemorrhage
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- **Astrocytoma**
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- Pilocytic astrocytoma (PA) > > pilomyxoid astrocytoma
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- **Pilocytic astrocytoma**: WHO grade 1, occurs throughout neuraxis, including optic chiasm/hypothalamus
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- Often has cyst and mural nodule appearance
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- **Pilomyxoid astrocytoma**considered subtype of PA
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- Hypothalamic/chiasmatic most common location
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- Affects infants and young children; median 10 months
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- Most suprasellar astrocytomas are solid, T2 hyperintense, not grossly cystic
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- Variable enhancement
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- **Ependymal Cyst**
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- Congenital, benign, ependymal-lined cyst
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- Lateral ventricle > > 3rd ventricle
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- Round/ovoid; CSF-like
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- Rare lesion
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- **Saccular Aneurysm**
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- Aneurysms may be associated with true perianeurysmal cysts
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- Obstructed perivascular spaces posited as etiology
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- Partly or completely thrombosed may have cystic-appearing foci within clot
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- Rare
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- Acute thrombosis can present with panhypopituitarism, subarachnoid hemorrhage (SAH)
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- Imaging can mimic necrotic adenoma
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- Hypodense center, iso-/hyperintense rim on T1WI
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- Look for mixed-age laminated clot
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- Blooms on GRE, SWI
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- Rim may enhance
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- **Pituitary Abscess**
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- Clinical signs of infection may be absent
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- May mimic pituitary apoplexy on MR
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- T1 shortening along rim and peripheral enhancement may be seen
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- DWI restriction characteristic
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- **Persistent Embryonic Infundibular Recess**
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- Rare congenital malformation of neurohypophysis
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- Enlarged infundibular recess follows CSF
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- Communicates with anterior 3rd ventricle
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- May mimic cystic mass
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- ## Alternative Differential Approaches
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- In **child**with suprasellar cystic mass, consider enlarged 3rd ventricle (aqueductal stenosis, hydrocephalus), craniopharyngioma, NCC, astrocytoma
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- In **adult**, consider AC, NCC, Rathke cleft cyst, adenoma, aneurysm
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## References
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# Selected References
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1. [Osborn AG et al: The 2021 World Health Organization Classification of Tumors of the Central Nervous System: what neuroradiologists need to know. AJNR Am J Neuroradiol. 43(7):928-37, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35710121%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. [Louis DN et al: The 2021 WHO Classification of Tumors of the Central Nervous System: a summary. Neuro Oncol. 23(8):1231-51, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34185076%5Bpmid%5D)
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1. [Shih RY et al: Primary tumors of the pituitary gland: radiologic-pathologic correlation. Radiographics. 41(7):2029-46, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34597177%5Bpmid%5D)
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1. [Agyei JO et al: Case report of a primary pituitary abscess and systematic literature review of pituitary abscess with a focus on patient outcomes. World Neurosurg. 101:76-92, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28153622%5Bpmid%5D)
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1. [Gao L et al: Pituitary abscess: clinical manifestations, diagnosis and treatment of 66 cases from a large pituitary center over 23 years. Pituitary. 20(2):189-94, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27696121%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. [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. [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. [Rosenfeld A et al: A case series characterizing pilomyxoid astrocytomas in childhood. J Pediatr Hematol Oncol. 38(2):e63-6, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26886222%5Bpmid%5D)
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1. [Alkonyi B et al: Differential imaging characteristics and dissemination potential of pilomyxoid astrocytomas versus pilocytic astrocytomas. Neuroradiology. 57(6):625-38, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25666233%5Bpmid%5D)
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1. [Deng S et al: Gliomas in the sellar turcica region: a retrospective study including adult cases and comparison with craniopharyngioma. Eur Neurol. 73(3-4):135-43, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25531372%5Bpmid%5D)
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1. [Park M et al: Differentiation between cystic pituitary adenomas and Rathke cleft cysts: a diagnostic model using MRI. AJNR Am J Neuroradiol. 36(10):1866-73, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26251436%5Bpmid%5D)
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## Images
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### Selected Images
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**Aqueductal Stenosis**
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*Sagittal T2WI MR shows massively enlarged 3rd <img src='img/arrows/CO.png'/> and lateral ventricles and an enlarged, funnel-shaped aqueduct <img src='img/arrows/CC.png'/> related to aqueductal stenosis in this child. There is also a medial atrial diverticulum <img src='img/arrows/BO.png'/> compressing the 4th ventricle <img src='img/arrows/WS.png'/>.*
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**Aqueductal Stenosis**
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*Sagittal T2WI MR shows massively enlarged 3rd <img src='img/arrows/CO.png'/> and lateral ventricles and an enlarged, funnel-shaped aqueduct <img src='img/arrows/CC.png'/> related to aqueductal stenosis in this child. There is also a medial atrial diverticulum <img src='img/arrows/BO.png'/> compressing the 4th ventricle <img src='img/arrows/WS.png'/>.*
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**Arachnoid Cyst**
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*Sagittal T2WI MR shows a cystic sellar and suprasellar mass <img src='img/arrows/CO.png'/> related to an arachnoid cyst (AC). These benign lesions follow CSF on all MR sequences and do not enhance. The normal pituitary gland is usually thinned and wrapped anteriorly around the AC.*
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**Craniopharyngioma**
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*Coronal T2 FS MR in a 7-year-old child with delayed growth shows a hyperintense suprasellar mass <img src='img/arrows/CS.png'/> related to an adamantinomatous craniopharyngioma. These tumors are known as the 90% tumor, as 90% are cystic, calcified, and enhancing.*
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**Craniopharyngioma**
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*Sagittal T1 C+ MR in a 32-year-old with headaches shows a mixed cystic <img src='img/arrows/CS.png'/> and solid <img src='img/arrows/CO.png'/> suprasellar mass. Although not seen in this case, papillary craniopharyngiomas often have more solid than cystic components. The papillary type is more common in adults.*
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**Neurocysticercosis**
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*Axial T2 MR shows racemose (multilobulated, grape-like) neurocysticercosis (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 an identifiable scolex.*
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**Rathke Cleft Cyst**
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*Coronal T2 MR shows a sellar/suprasellar cyst <img src='img/arrows/CO.png'/> in a 29-year-old woman with mild prolactin elevation. Rathke cleft cysts may present with symptoms related to mass effect. The prolactin elevation in this case was related to stalk effect from the cyst compressing the stalk.*
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**Pituitary Macroadenoma**
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*Coronal T1 C+ MR shows a cystic macroadenoma <img src='img/arrows/CO.png'/> with mild mass effect on the left optic chiasm <img src='img/arrows/WS.png'/>. Imaging in this young adult female with amenorrhea and markedly elevated prolactin mimics a Rathke cleft cyst.*
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**Dermoid Cyst**
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*Sagittal T1 MR shows a large midline mass with intrinsic T1 shortening within the subfrontal region above the optic chiasm along the 3rd ventricular floor <img src='img/arrows/WS.png'/>. T1-hyperintense "droplets" are seen scattered throughout the subarachnoid space <img src='img/arrows/WO.png'/> related to a ruptured dermoid.*
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**Epidermoid Cyst**
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*Axial DWI MR shows an epidermoid cyst in the left suprasellar cistern <img src='img/arrows/CS.png'/>. These benign cysts classically show restricted diffusion as seen in this example. They are often T2 hyperintense and lack suppression on FLAIR sequences. Surgical resection is the treatment of choice.*
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**Enlarged Perivascular Spaces**
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*Sagittal T1WI MR in a 15-year-old with headaches shows multiple CSF-like cysts in the hypothalamus, thalamus, and midbrain <img src='img/arrows/BS.png'/> that bulge into the suprasellar subarachnoid space <img src='img/arrows/BO.png'/>.*
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**Pituitary Apoplexy**
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*Axial T2 MR shows a large pituitary macroadenoma <img src='img/arrows/CS.png'/> with cavernous sinus invasion on the right. There is a blood fluid level <img src='img/arrows/CO.png'/> related to hemorrhage in this patient who presented with acute headache, visual changes, and ophthalmoplegia. Pituitary apoplexy may be caused by hemorrhage or infarction of the pituitary gland, often within an adenoma.*
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**Pilomyxoid Astrocytoma**
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*Sagittal T2WI MR shows a very hyperintense suprasellar mass, almost as bright as CSF. A thin rim of normal-looking brain borders the mass <img src='img/arrows/BS.png'/>, indicating its intraaxial origin.*
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**Saccular Aneurysm**
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*Axial T1WI MR shows a partially thrombosed saccular aneurysm <img src='img/arrows/WS.png'/>. Part of the clot is very hypointense <img src='img/arrows/WC.png'/> and is seen here as a mass in the suprasellar cistern.*
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**Pituitary Abscess**
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*Coronal DWI MR shows diffusion restriction in the pituitary fossa <img src='img/arrows/WO.png'/> in this 71-year-old woman with a sellar abscess. The patient presented with altered mental status and meningitis. Additional focus of DWI hyperintensity <img src='img/arrows/WS.png'/> is related to the patient's meningitis. Diffuse meningeal enhancement was seen on postcontrast images (not shown).*
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### Additional Images
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**Enlarged 3rd Ventricle**
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*Sagittal T2WI MR shows obstructive hydrocephalus with markedly enlarged lateral <img src='img/arrows/CS.png'/> and 3rd <img src='img/arrows/CO.png'/> ventricles. The CSF suprasellar mass was related to an enlarged 3rd ventricle from a pineal region germinoma <img src='img/arrows/WO.png'/>. Germinomas most commonly present in the pineal region.*
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**Obstructive Hydrocephalus**
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*Sagittal T2WI MR shows extraventricular obstructive hydrocephalus (EVOH) with markedly enlarged lateral <img src='img/arrows/WS.png'/>, 3rd <img src='img/arrows/WO.png'/>, and 4th <img src='img/arrows/WC.png'/> ventricles. A CSF suprasellar mass caused by an enlarged 3rd ventricle was diagnosed.*
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**Arachnoid Cyst**
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*Coronal T1 C+ MR shows a large CSF-like cyst that elevates and compresses the 3rd ventricle <img src='img/arrows/WO.png'/> and causes obstructive hydrocephalus. Note straight cyst margins <img src='img/arrows/BS.png'/>.*
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**Arachnoid Cyst**
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*Sagittal T2WI FS MR shows a lobulated, sharply marginated, CSF-like, suprasellar cyst <img src='img/arrows/WS.png'/> extending into the sella <img src='img/arrows/WO.png'/>, elevating the 3rd ventricle <img src='img/arrows/BC.png'/>, and causing obstructive hydrocephalus.*
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**Arachnoid Cyst**
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*Coronal T2WI MR shows a small AC in the suprasellar cistern that elevates and compresses the optic chiasm. Note both intra- <img src='img/arrows/WO.png'/> and suprasellar <img src='img/arrows/BS.png'/> components of the cyst.*
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**Craniopharyngioma**
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*Coronal T2WI FS MR in an 8-year-old child with delayed growth shows a hyperintense suprasellar mass <img src='img/arrows/WS.png'/> that slightly compresses and displaces the pituitary gland <img src='img/arrows/WO.png'/> toward the left.*
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**Craniopharyngioma**
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*Sagittal gross pathology, section shows a classic craniopharyngioma with a large suprasellar cystic component <img src='img/arrows/BS.png'/>. Smaller intrasellar component is present <img src='img/arrows/WC.png'/>. (Courtesy R. Hewlett, MD.)*
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**Craniopharyngioma**
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*Sagittal T2WI MR in a 32-year-old with headaches and lethargy shows a hyperintense mixed cystic <img src='img/arrows/CS.png'/> and solid <img src='img/arrows/CO.png'/> suprasellar mass that extends superiorly into the 3rd ventricle and results in mass effect on the midbrain. This was pathologically proven to represent a papillary craniopharyngioma. Although not seen in this case, papillary craniopharyngiomas tend to have more solid than cystic components. The papillary subtype is more commonly seen in the adult population and is overall less common than the adamantinomatous subtype.*
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**Rathke Cleft Cyst**
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*Sagittal T1 C+ MR shows an intra- and suprasellar cyst that does not enhance. Note the displaced pituitary gland and infundibular stalk <img src='img/arrows/WS.png'/> form a "claw" around the lesion.*
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**Neurocysticercosis**
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*Coronal T2WI MR shows a suprasellar cystic mass <img src='img/arrows/WS.png'/> and a moderate compensated hydrocephalus. Another cyst is present in the right Meckel cave <img src='img/arrows/WO.png'/> in this patient with racemose NCC.*
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**Neurocysticercosis**
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*Coronal T1 C+ MR shows racemose neurocysticercosis with multiple cysts in the suprasellar cistern <img src='img/arrows/BS.png'/> and 3rd ventricle <img src='img/arrows/BO.png'/>. Enhancement <img src='img/arrows/BC.png'/> in the right sylvian fissure is present.*
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**Enlarged Perivascular Spaces**
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*Axial NECT shows multiple clusters of CSF-like cysts <img src='img/arrows/WS.png'/>. These are actually in brain parenchyma, helping distinguish them from other suprasellar cystic lesions.*
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**Epidermoid Cyst**
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*Coronal T2WI MR shows an epidermoid cyst in the left suprasellar cistern <img src='img/arrows/CS.png'/> with mass effect on the optic chiasm <img src='img/arrows/CO.png'/> superiorly and the pituitary gland <img src='img/arrows/WS.png'/> inferiorly. These benign cysts classically show restricted diffusion and lack suppression on FLAIR sequences. Surgical resection is the treatment of choice.*
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**Epidermoid Cyst**
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*Axial T2WI MR shows an epidermoid cyst in the suprasellar cistern, widening the interpeduncular fossa <img src='img/arrows/WS.png'/> and extending into the ambient and quadrigeminal cisterns.*
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**Epidermoid Cyst**
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*Coronal T2WI MR shows an epidermoid cyst in the suprasellar cistern <img src='img/arrows/CS.png'/> with a lobulated appearance and associated ventriculomegaly. These benign cysts classically show restricted diffusion and lack suppression on FLAIR sequences. Surgical resection is the treatment of choice.*
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**Pituitary Macroadenoma**
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*Coronal T2 MR shows a cystic macroadenoma <img src='img/arrows/CO.png'/> with mild mass effect on the left optic chiasm <img src='img/arrows/WS.png'/> in a 41-year-old with elevated growth hormone.*
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**Pituitary Macroadenoma**
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*Axial T1 C+ MR shows 2 neoplasm-associated cysts: A large trapped perivascular space <img src='img/arrows/WO.png'/> caused by a pituitary macroadenoma <img src='img/arrows/BS.png'/> and a small intratumoral cyst <img src='img/arrows/BO.png'/> within the adenoma.*
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**Pituitary Apoplexy**
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*Axial CECT shows pituitary apoplexy caused by a necrotic pituitary macroadenoma <img src='img/arrows/WS.png'/>. Imaging appearance resembles a thrombosed aneurysm.*
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**Dermoid Cyst**
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*Axial NECT shows a large, mixed density suprasellar and subfrontal mass <img src='img/arrows/WS.png'/>. Low density "droplets" that resemble fat are seen in the adjacent sylvian fissure <img src='img/arrows/WO.png'/> in this patient with a ruptured dermoid. Ca⁺⁺ may be seen in up to 20% of dermoid cysts.*
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**Ependymal Cyst**
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*Sagittal STIR MR with a close-up view shows a large cystic lesion within the 3rd ventricle <img src='img/arrows/WS.png'/>. The lateral ventricles <img src='img/arrows/WO.png'/> are markedly enlarged, but the 4th ventricle <img src='img/arrows/WC.png'/> is normal.*
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