statdx/docs_md/articles/suprasellar-mass-adult_52e755e0-b4b7-4a4d-a8ad-04480ca1768c.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
Suprasellar Mass, Adult	52e755e0-b4b7-4a4d-a8ad-04480ca1768c	key value 8d5254e9-8dda-478b-8f08-bdee97a32c79 Karen L. Salzman, 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 Suprasellar Mass, Adult suprasellar-mass-adult null	Brain	66d7ead4-462e-4ae9-8711-56d7a77301d4	31	02/02/23	Suprasellar Mass, Adult	Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Suprasellar Mass, Adult	Suprasellar Mass, Adult | STATdx	Suprasellar Mass, Adult	DDX	true	Brain Differential Diagnosis Sella/Juxtasellar, Pineal Region Anatomically Based Differentials Suprasellar Mass, Adult

---

title: "Suprasellar Mass, Adult" docid: "52e755e0-b4b7-4a4d-a8ad-04480ca1768c" authors:

• key: "8d5254e9-8dda-478b-8f08-bdee97a32c79" value: "Karen L. Salzman, 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: "Suprasellar Mass, Adult" slug: "suprasellar-mass-adult" treeNodeId: null category: "Brain" documentVersionId: "66d7ead4-462e-4ae9-8711-56d7a77301d4" imageCount: 31 lastUpdated: "02/02/23" pageDescription: "Suprasellar Mass, Adult" pageKeywords: "Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Suprasellar Mass, Adult" pageTitle: "Suprasellar Mass, Adult | STATdx" enhancedTitle: "Suprasellar Mass, Adult" type: "DDX" references: true breadcrumbs:
• "Brain"
• "Differential Diagnosis"
• "Sella/Juxtasellar, Pineal Region"
• "Anatomically Based Differentials"
• "Suprasellar Mass, Adult"

---

ESSENTIAL INFORMATION

• Key Differential Diagnosis Issues

  • Is mass extraaxial or intraaxial?
  • Extraaxialmasses arise from pituitary/infundibulum, meninges, vessels - If extraaxial mass appears to arise from pituitary/infundibulum, determine origin of mass as precisely as possible - Pituitary gland: Think macroadenoma, physiologic hyperplasia, hypophysitis - Infundibular stalk: Neurosarcoid, Langerhans cell histiocytosis (LCH), germinoma, histiocytosis, lymphoma, IgG4-related disease (IgG4-RD), pituicytoma - Nonpituitary extraaxial masses (normal pituitary gland can usually be identified inferior to lesion) - Meningioma - Saccular aneurysm - Craniopharyngioma - Rathke cleft cyst - Arachnoid cyst
  • Intraaxialmasses arise from chiasm/hypothalamus - Optic chiasm/hypothalamus: Pilocytic or pilomyxoid astrocytoma, tuber cinereum hamartoma (more common in children)
  • Anterior 3rd ventricle masses - Craniopharyngioma (papillary subtype), chordoid glioma

• Helpful Clues for Common Diagnoses

  • Pituitary Macroadenoma - Gland cannot be separated from mass; gland is mass - Enhancing sellar and suprasellar pituitary mass - Most common suprasellar mass in adults
  • Meningioma - Suprasellar meningiomas are separated from pituitary gland by hypointense diaphragma sella - Often occurs along planum sphenoidale - Homogeneous enhancement - May have hyperostosis of adjacent bones
  • Saccular Aneurysm - May arise from carotid arteries or basilar artery - Often partially thrombosed - Look for residual patent lumen, phase artifact - CTA or MRA helpful for diagnosis
  • Rathke Cleft Cyst - May be intrasellar (~ 40%), suprasellar, or both - Typically T2 hyperintense and nonenhancing ("claw" of enhancing pituitary tissue may surround mass) - Intracystic nodule (up to 75%) virtually pathognomonic - Rarely calcifies
  • Adamantinomatous****Craniopharyngioma - "90% tumor": Occurs in children and adults - 90% cystic (may have multiple; density/signal intensity varies with content) - 90% Ca⁺⁺ (globular, rim) - 90% enhance (rim, nodule)
  • Papillary Craniopharyngioma - Occurs in adults - Solid, enhancing mass commonly - May be cystic or mixed cystic/solid
  • Pituitary Hyperplasia - Physiologic: Enlarged gland secondary to pregnancy, lactation, or puberty - Pathologic: Related to end-organ failure (commonly hypothyroidism)
  • Arachnoid Cyst - 10% suprasellar - Sharply marginated, CSF-like cyst - Sagittal T1- or T2WI shows 3rd ventricle elevated, compressed over cyst - Follows CSF on all sequences, including FLAIR, DWI

• Helpful Clues for Less Common Diagnoses

  • Diffuse Astrocytoma, Low Grade - Includes astrocytoma, IDH-mutant & pediatric diffuse low-grade gliomas - T2-hyperintense mass - Variable enhancement
  • Pilocytic Astrocytoma - Most occur in children 5-15 years of age, WHO grade 1 - Enlarged optic nerve/chiasm/tract - T1 solid, iso-/hypointense; T2 hyperintense - May have cyst and mural nodule - Variable enhancement (none to intense)
  • Pilomyxoid Astrocytoma - Subtype of pilocytic astrocytoma - Large, bulky suprasellar mass in infant or young child - May be H-shaped - May hemorrhage (rare in pilocytic astrocytoma)
  • Neurosarcoid - Multisystem inflammatory disease, often CNS and other systems - Pulmonary hilar lymph nodes most commonly involved - Enhancing masses, may affect pituitary axis - CNS involved without systemic disease in 5-10%
  • Langerhans Cell Histiocytosis - May occur in children and adults; if child, usually < 2 years - Patients often present with diabetes insipidus (DI) - Up to 50% of LCH cases involve stalk, pituitary gland ± hypothalamus - Rare: Choroid plexus, leptomeninges, cerebellar white matter, brain parenchyma - Look for lytic skull lesion(s) with beveled edges
  • Epidermoid Cyst - Nonenhancing suprasellar mass - Follows CSF signal intensity on T1, T2 - DWI hyperintense; incomplete suppression on FLAIR
  • Dermoid Cyst - T1 hyperintense - Rarely calcifies (~ 10-20%) - May see fatty droplets in CSF if ruptures
  • Germinoma - ~ 25-35% involve pituitary gland/stalk, enhancing mass - Often presents with DI - Midline germ cell tumor, typically hyperdense on CT - WHO grade 2
  • Neurocysticercosis - Racemose (lobular, grape-like) cysts may fill basal cisterns - Lacks typical scolex, no Ca⁺⁺ typical - No enhancement of cysts; may have associated meningitis
  • Lipoma - Fatty, benign hypothalamic mass - No enhancement

• Helpful Clues for Rare Diagnoses

  • Pituitary Apoplexy - Acute clinical syndrome with headache, nausea, visual deficits, variable cranial neuropathies (CNIII-CNVI) - Caused by hemorrhage into or ischemic necrosis of pituitary - Often macroadenoma is present - Occurs in ~ 1% of patients with macroadenomas
  • Lymphocytic Hypophysitis - Inflammatory disorder; may be autoimmune, granulomatous (sarcoid, LCH), IgG4-RD or drug related - Often affects peripartum females - Can mimic macroadenoma and pituitary apoplexy
  • Pituicytoma - Enhancing mass along infundibulum &/or neurohypophysis - WHO grade 1
  • Granular Cell Tumor - Enhancing mass along infundibulum &/or neurohypophysis - WHO grade 1
  • Spindle Cell Oncocytoma - Enhancing sellar/suprasellar mass - Mimics much more common pituitary adenoma - WHO grade 1
  • Chordoid Glioma of 3rd Ventricle - Enhancing mass along anterior 3rd ventricle - WHO grade 2
  • Lymphoma, Primary CNS - Enhancing, often infiltrative mass along pituitary axis - Can mimic hypophysitis, sarcoid, LCH, germinoma
  • Metastases - Primary tumor often known - Metastases to stalk and gland is rare
  • IgG4-Related Disease - Fibroinflammatory disease with IgG4(+) plasma cell infiltrates - Diffusely infiltrating, enhancing mass - May cause pituitary or infundibular mass

• Alternative Differential Approaches

  • Cystic suprasellar mass (adult): Consider pituitary adenoma, craniopharyngioma, arachnoid cyst, epidermoid cyst
  • Calcified suprasellar mass (adult): Consider craniopharyngioma, meningioma, aneurysm, neurocysticercosis
  • T1-hyperintense suprasellar mass (adult): Consider pituitary adenoma/apoplexy, craniopharyngioma, Rathke cleft cyst, dermoid, thrombosed saccular aneurysm, lipoma

References

Selected References

1. Amereller F et al: Differences between immunotherapy-induced and primary hypophysitis-a multicenter retrospective study. Pituitary. 25(1):152-8, 2022
2. Husebye ES et al: Endocrine-related adverse conditions in patients receiving immune checkpoint inhibition: an ESE clinical practice guideline. Eur J Endocrinol. 187(6):G1-21, 2022
3. Langlois F et al: Hypophysitis, the growing spectrum of a rare pituitary disease. J Clin Endocrinol Metab. 107(1):10-28, 2022
4. Louis DW et al: Tumours of the sellar region. In: WHO Classification of Tumours of the Central Nervous System. International Agency for Research on Cancer. 391-415, 2021
5. Amirbaigloo A et al: IgG4-related hypophysitis. Endocrine. 73(2):270-91, 2021
6. Angelousi A et al: Diabetes insipidus secondary to sellar/parasellar lesions. J Neuroendocrinol. 33(3):e12954, 2021
7. Ouyang T et al: Imaging of neurologic injury following oncologic therapy. Radiol Clin North Am. 59(3):425-40, 2021
8. Shih RY et al: Primary tumors of the pituitary gland: radiologic-pathologic correlation. Radiographics. 41(7):2029-46, 2021
9. Yang B et al: Chordoid glioma: an entity occurring not exclusively in the third ventricle. Neurosurg Rev. 43(5):1315-22, 2020
10. 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
11. Erwood AA et al: Chordoid glioma of the third ventricle: report of a rapidly progressive case. J Neurooncol. 132(3):487-95, 2017
12. Nakassa AC et al: Complete endoscopic resection of a pituitary stalk epidermoid cyst using a combined infrasellar interpituitary and suprasellar endonasal approach: case report. J Neurosurg. 1-7, 2017
13. Zamora C et al: Sellar and parasellar imaging. Neurosurgery. 80(1):17-38, 2017
14. Gagliardi F et al: Suprasellar granular cell tumor of the neurohypophysis: surgical outcome of a very rare tumor. Pituitary. 19(3):277-85, 2016
15. Ma X et al: Pilomyxoid astrocytomas with rare rosenthal fibers. Brain Tumor Pathol. 33(1):35-9, 2016
16. Tarabay A et al: Primary pituitary lymphoma: an update of the literature. J Neurooncol. 130(3):383-95, 2016

Images

Selected Images

Pituitary Macroadenoma Coronal T1 C+ FS MR shows a large sellar and suprasellar mass with mild superior displacement of the optic chiasm . A macroadenoma is the most common suprasellar mass in an adult. In these tumors, a normal pituitary gland cannot be separated from the adenoma.

Pituitary Macroadenoma Coronal T1 C+ FS MR shows a large sellar and suprasellar mass with mild superior displacement of the optic chiasm . A macroadenoma is the most common suprasellar mass in an adult. In these tumors, a normal pituitary gland cannot be separated from the adenoma.

Meningioma Sagittal T1 C+ FS MR shows an enhancing suprasellar meningioma with a dural tail along the planum sphenoidale and hyperostosis of the adjacent bone . Note the separate pituitary gland is seen inferiorly within the normal-sized sella turcica .

Saccular Aneurysm AP DSA of internal carotid artery injection shows a giant internal carotid artery aneurysm , > 2.5 cm, in this 63-year-old woman. Saccular aneurysms are the 3rd most common suprasellar mass in adults. The enhancement pattern is variable, depending on the patency of the aneurysm.

Rathke Cleft Cyst Coronal T1 MR shows a hyperintense suprasellar mass . No enhancement was present. Rathke cleft cysts are benign and may become symptomatic when large, resulting in mass effect on the surrounding structures.

Craniopharyngioma Axial NECT shows a calcified suprasellar mass in an adult related to craniopharyngioma. Adamantinomatous craniopharyngiomas are known as the "90% tumor" as 90% calcify, 90% are cystic, and 90% enhance. This tumor has a bimodal age peak occurring in children and adults.

Craniopharyngioma Sagittal T1 FS C+ MR shows an enhancing, solid and cystic suprasellar mass related to a papillary craniopharyngioma. Papillary craniopharyngiomas occur in adults and are typically solid or mixed solid and cystic.

Pituitary Hyperplasia Coronal T1 C+ MR shows an enlarged sellar and suprasellar mass that nearly contacts the optic chiasm. This patient was found to have pituitary hyperplasia related to hypothyroidism. After therapy, the pituitary gland returned to normal size.

Arachnoid Cyst Coronal T1 C+ MR shows a large, cystic suprasellar mass with no enhancement. There is associated enlargement of the sella turcica . Arachnoid cysts follow CSF signal on all sequences. These benign cysts are often treated with surgical fenestration.

Diffuse Astrocytoma, Low Grade Sagittal T1 C+ MR shows a nonenhancing suprasellar mass , separate from the pituitary gland. An astrocytoma, IDH-mutant WHO grade 2 was found at biopsy. These tumors are typically T2 hyperintense and have no enhancement.

Pilocytic Astrocytoma Coronal T1 C+ MR shows an enhancing suprasellar mass with an associated cyst wrapping around the optic chiasm . These WHO grade 1 tumors are commonly found in children and young adults. A cyst and nodule appearance is typical.

Neurosarcoid Coronal T1 C+ FS MR shows an enhancing suprasellar mass in this female patient with neurosarcoid. Patients may present with single or multiple enhancing masses in the CNS. Patients with pituitary axis involvement may present with diabetes insipidus. Cranial nerve enhancement may also be seen.

Dermoid Cyst Axial NECT shows a suprasellar mass with fat density related to a dermoid cyst. Note the fatty deposits in the subarachnoid spaces related to rupture of the dermoid. Rupture may result in a chemical meningitis.

Germinoma Sagittal T1 C+ MR shows enhancing masses in the pineal region with thickening of the infundibulum . Enhancement is also seen in the optic recess of the 3rd ventricle , related to germinoma. Synchronous involvement of the pineal and suprasellar regions is typical of germinoma.

Granular Cell Tumor Coronal T1 C+ FS MR shows an enhancing suprasellar mass . Granular cell tumor was diagnosed at resection. These rare WHO grade 1 tumors are typically located along the infundibulum or neurohypophysis.

Additional Images

Meningioma Sagittal T1 C+ FS MR shows an enhancing suprasellar meningioma with a dural tail along the planum sphenoidale. Note the normal pituitary gland is seen inferiorly within the normal-sized sella turcica . The normal pituitary gland enhances brighter than the meningioma.

Pituitary Macroadenoma Coronal T1 C+ FS MR shows a large sellar and suprasellar mass with extension along the superior right cavernous carotid artery, suggesting possible cavernous sinus invasion .

Pituitary Macroadenoma Coronal T1 C+ FS MR shows a large sellar and suprasellar mass with encasement of the left cavernous carotid artery. The macroadenoma extends between the cavernous carotid artery and the lateral dura, indicating cavernous sinus invasion .

Rathke Cleft Cyst Axial NECT shows a large sellar and suprasellar cyst. Note the lack of calcifications.

Craniopharyngioma Sagittal T1WI MR shows typical cysts of varying signal intensity in the suprasellar cistern, herniating into the 3rd ventricle. There is enlargement of the bony sella and erosion of the dorsum sella .

Craniopharyngioma Coronal T2WI MR shows calcification at the base of the lesion .

Arachnoid Cyst Coronal T2WI MR shows erosion of the dorsum sella, upward displacement of the hypothalamus, and extension into the right middle cranial fossa caused by suprasellar arachnoid cyst .

Pilomyxoid Astrocytoma Sagittal T2WI MR shows a large, very hyperintense, suprasellar pilomyxoid astrocytoma that displaces the mesencephalon posteriorly.

Pilomyxoid Astrocytoma Axial T1WI MR shows encasement of the circle of Willis.

Pilomyxoid Astrocytoma Axial T1 C+ FS MR in the same patient shows inhomogeneous enhancement and extension into the cistern of the right middle cerebral artery.

Pilocytic Astrocytoma Coronal T1 C+ MR shows chiasmatic glioma. The prechiasmatic optic nerves are expanded and surrounded by enhancing tumor.

Pilocytic Astrocytoma Coronal T1 C+ MR shows a very large suprasellar pilocytic astrocytoma. This solid and cystic mass involves the suprasellar cistern, the chiasm, and the hypothalamus, and protrudes into the 3rd ventricle.

Germinoma Sagittal T2WI MR shows typical synchronous suprasellar and pineal masses in a teenager who presented with signs of increased intracranial pressure. Note the increased signal in the body of the corpus callosum at the site of the hippocampal commissure disruption caused by acute hydrocephalus.

Germinoma Sagittal T1 C+ MR shows enhancing pineal and suprasellar masses with associated obstruction at the proximal cerebral aqueduct and enlargement of the 3rd ventricle. Synchronous involvement of the pineal and suprasellar regions is typical of germinoma.

Metastases Axial T1WI MR shows a multilobed lipoma in the suprasellar cistern.

Lipoma Sagittal T1 C+ FS MR in the same patient shows loss of signal in a lipoma following fat saturation.

Pituitary Macroadenoma Sagittal T1 C+ FS MR in a pregnant teenager who developed acute onset of vision problems late in the 3rd trimester shows a large, enhancing mass with reactive dural thickening . The preoperative diagnosis was macroadenoma.