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Enhancing Suprasellar Mass 528eaea9-095f-4fab-ad42-5ad84e215a2d
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318f80ab-6abb-4067-a809-2ebdaa5a30c9 Kalen Riley, MD, MBA
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5cff4116-3654-4b3a-bb75-5ebe0b8c9850 Anne G. Osborn, MD, FACR
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8d5254e9-8dda-478b-8f08-bdee97a32c79 Karen L. Salzman, MD, FACR
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Brain 01b1cc14-8442-4bbd-93ff-bd8895b90f87 39bca65a-aa9f-4818-9b63-d727551a81f1 19 01/26/23 Enhancing Suprasellar Mass Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Enhancing Suprasellar Mass Enhancing Suprasellar Mass | STATdx Enhancing Suprasellar Mass DDX true
Brain
Differential Diagnosis
Sella/Juxtasellar, Pineal Region
Anatomically Based Differentials
Enhancing Suprasellar Mass

title: "Enhancing Suprasellar Mass" docid: "528eaea9-095f-4fab-ad42-5ad84e215a2d" authors:

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  • "Brain"
  • "Differential Diagnosis"
  • "Sella/Juxtasellar, Pineal Region"
  • "Anatomically Based Differentials"
  • "Enhancing Suprasellar Mass"

ESSENTIAL INFORMATION

  • Key Differential Diagnosis Issues

    • Effect of age on differential diagnosis important
    • Common lesions ("big 5") account for > 75% of all suprasellar masses
    • Most other lesions < 1-2% each
    • Differential diagnosis narrows if mass confined to infundibulum

  • Helpful Clues for Common Diagnoses

    • Pituitary Macroadenoma vs. Meningioma - Macroadenoma: Gland cannot be identified separate from mass - Meningioma: Mass distinct from gland (diaphragma sellae separates mass above from pituitary below)
    • SaccularAneurysm - Coronal plane helps distinguish aneurysm from pituitary - Look for phase artifact, flow void on MR
    • Craniopharyngioma - Adamantinomatous: 90% Ca⁺⁺, 90% cystic, 90% enhance - Papillary may be solid, noncalcified, enhance strongly
    • Pilocytic Astrocytoma - More common in children than adults - T2 hyperintense, variable enhancement - Expands hypothalamus, optic chiasm - May extend into optic nerves/tracts
    • Pilomyxoid Astrocytoma - Subtype of pilocytic astrocytoma, more aggressive - Infant > child - Large, bulky tumor with lateral extension to temporal lobe common - Hemorrhage in 20-25%

  • Helpful Clues for Less Common Diagnoses

    • Pituitary Hyperplasia - May be physiologic (pregnancy, lactation, puberty) - Pathologic in end-organ failure (thyroid, ovarian, etc.)
    • Neurosarcoid - Older patients, enhancing mass
    • Langerhans Cell Histiocytosis - Children and young adults; enhancing mass - May cause thickened infundibulum - Absence of pituitary "bright spot"
    • Germinoma - Children > > adults; enhancing mass - CT hyperdense - May cause thickened infundibulum - Absence of the pituitary "bright spot"
    • Lymphocytic Hypophysitis - Can mimic pituitary adenoma on imaging - Most common in peripartum female - May be autoimmune, inflammatory, granulomatous process, drug related - May be secondary to checkpoint inhibitor therapy
    • Astrocytoma, IDH-Mutant - May affect hypothalamic and suprasellar regions - T2 hyperintense; variable enhancement - WHO grades 2-4

  • Helpful Clues for Rare Diagnoses

    • Solitarymetastasis to gland &/or stalk rare
    • Lymphoma, leukemia usually with systemic disease
    • Pituicytoma, g****ranular cell tumor, and spindle cell oncocytoma are rare tumors, which may occur along infundibulum &/or posterior pituitary or may mimic macroadenoma

  • Alternative Differential Approaches

    • Adult: Consider adenoma, meningioma, and aneurysm
    • Child: Craniopharyngioma, astrocytoma, Langerhans cell histiocytosis, and germinoma

References

Selected References

  1. Kinoshita Y et al: Natural course of Rathke's cleft cysts and risk factors for progression. J Neurosurg. 1-7, 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. Poyuran R et al: Nonneoplastic and noninfective cysts of the central nervous system: a histopathological study. Neuropathology. ePub, 2022
  4. Jipa A et al: Imaging of the sellar and parasellar regions. Clin Imaging. 77:254-75, 2021
  5. Kurokawa R et al: MRI findings of immune checkpoint inhibitor-induced hypophysitis: possible association with fibrosis. AJNR Am J Neuroradiol. 41(9):1683-9, 2020
  6. Go JL et al: Imaging of the sella and parasellar region. Radiol Clin North Am. 55(1):83-101, 2017
  7. Seeburg DP et al: Imaging of the sella and parasellar region in the pediatric population. Neuroimaging Clin N Am. 27(1):99-121, 2017
  8. Zamora C et al: Sellar and parasellar imaging. Neurosurgery. 80(1):17-38, 2017
  9. Patel KS et al: Intraoperative magnetic resonance imaging assessment of non-functioning pituitary adenomas during transsphenoidal surgery. Pituitary. 19(2):222-31, 2016
  10. 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
  11. Wang J et al: The clinicopathological features of pituicytoma and the differential diagnosis of sellar glioma. Neuropathology. 36(5):432-440, 2016
  12. Wu AW et al: Chondroid chordoma of the sella turcica mimicking a pituitary adenoma. Ear Nose Throat J. 94(10-11):E47-9, 2015
  13. DW Louis, et. al (Editors). WHO Classification of Tumours of the Central Nervous System. International Agency for Research on Cancer, Lyon, 2016. Chapter 17: Tumours of the sellar region, pp 323-334.

Images

Selected Images

Coronal T1 C+ MR shows an enhancing intrasellar and suprasellar mass . The pituitary gland cannot be separated from the mass and indeed is the mass. Note the superior displacement of the optic chiasm by the macroadenoma. Pituitary Macroadenoma Coronal T1 C+ MR shows an enhancing intrasellar and suprasellar mass . The pituitary gland cannot be separated from the mass and indeed is the mass. Note the superior displacement of the optic chiasm by the macroadenoma.

Coronal T1 C+ MR shows an enhancing intrasellar and suprasellar mass . The pituitary gland cannot be separated from the mass and indeed is the mass. Note the superior displacement of the optic chiasm by the macroadenoma. Pituitary Macroadenoma Coronal T1 C+ MR shows an enhancing intrasellar and suprasellar mass . The pituitary gland cannot be separated from the mass and indeed is the mass. Note the superior displacement of the optic chiasm by the macroadenoma.

Coronal T1 C+ FS MR shows a suprasellar enhancing mass separate from the normal pituitary gland below . Meningiomas often have associated hyperostosis of the adjacent bone. Additionally, these benign tumors enhance homogeneously and may have an associated dural tail. Meningioma Coronal T1 C+ FS MR shows a suprasellar enhancing mass separate from the normal pituitary gland below . Meningiomas often have associated hyperostosis of the adjacent bone. Additionally, these benign tumors enhance homogeneously and may have an associated dural tail.

Axial T1 C+ MR shows a suprasellar enhancing mass with prominent phase artifact caused by large basilar tip aneurysm with slow intraluminal flow. Aneurysms are the 3rd most common suprasellar mass in an adult. Saccular Aneurysm Axial T1 C+ MR shows a suprasellar enhancing mass with prominent phase artifact caused by large basilar tip aneurysm with slow intraluminal flow. Aneurysms are the 3rd most common suprasellar mass in an adult.

Sagittal T1 C+ MR shows an enhancing, partially solid and cystic suprasellar mass related to an adamantinomatous craniopharyngioma. These WHO grade 1 tumors are the most common pediatric intracranial tumor of nonglial origin. Craniopharyngioma Sagittal T1 C+ MR shows an enhancing, partially solid and cystic suprasellar mass related to an adamantinomatous craniopharyngioma. These WHO grade 1 tumors are the most common pediatric intracranial tumor of nonglial origin.

Coronal T1 C+ FS MR shows a heterogeneously enhancing suprasellar mass in a child that was found to represent a pilomyxoid astrocytoma, WHO grade 1. Pilomyxoid astrocytoma is a subtype of pilocytic astrocytoma that is often more aggressive. Pilomyxoid Astrocytoma Coronal T1 C+ FS MR shows a heterogeneously enhancing suprasellar mass in a child that was found to represent a pilomyxoid astrocytoma, WHO grade 1. Pilomyxoid astrocytoma is a subtype of pilocytic astrocytoma that is often more aggressive.

Axial T1 C+ FS MR shows a lobular, enhancing suprasellar mass related to neurosarcoid. Patients with neurosarcoid often have associated pulmonary hilar adenopathy. Neurosarcoid Axial T1 C+ FS MR shows a lobular, enhancing suprasellar mass related to neurosarcoid. Patients with neurosarcoid often have associated pulmonary hilar adenopathy.

Axial T1 C+ FS MR shows a diffusely enhancing suprasellar mass in a young adult who first presented with diabetes insipidus and a thick, enhancing infundibulum with absence of a posterior pituitary bright spot. Nine months later, patient returned with a much larger suprasellar mass. Langerhans Cell Histiocytosis Axial T1 C+ FS MR shows a diffusely enhancing suprasellar mass in a young adult who first presented with diabetes insipidus and a thick, enhancing infundibulum with absence of a posterior pituitary bright spot. Nine months later, patient returned with a much larger suprasellar mass.

Coronal T2 MR in a pregnant patient with acute vision problems shows a sellar and suprasellar mass with superior displacement of the optic chiasm . Imaging of lymphocytic hypophysitis may mimic a pituitary macroadenoma. Lymphocytic Hypophysitis Coronal T2 MR in a pregnant patient with acute vision problems shows a sellar and suprasellar mass with superior displacement of the optic chiasm . Imaging of lymphocytic hypophysitis may mimic a pituitary macroadenoma.

Additional Images

Coronal T1 C+ MR shows an inhomogeneously enhancing intra- and suprasellar mass ; the pituitary gland cannot be found separate from it and indeed is the mass. Pituitary Macroadenoma Coronal T1 C+ MR shows an inhomogeneously enhancing intra- and suprasellar mass ; the pituitary gland cannot be found separate from it and indeed is the mass.

Coronal T1 C+ FS MR shows a suprasellar enhancing mass separated from the normal pituitary gland below by a thin black line of diaphragma sellae . Meningioma Coronal T1 C+ FS MR shows a suprasellar enhancing mass separated from the normal pituitary gland below by a thin black line of diaphragma sellae .

Coronal T1 C+ MR in a child shows a intra-/suprasellar mass. An apical nonenhancing portion is surrounded by a thin enhancing rim . The solid portion enhances strongly but heterogeneously . Craniopharyngioma Coronal T1 C+ MR in a child shows a intra-/suprasellar mass. An apical nonenhancing portion is surrounded by a thin enhancing rim . The solid portion enhances strongly but heterogeneously .

Sagittal T1 C+ FS MR shows a papillary craniopharyngioma in an adult man. Papillary craniopharyngiomas are most often solid masses. Craniopharyngioma Sagittal T1 C+ FS MR shows a papillary craniopharyngioma in an adult man. Papillary craniopharyngiomas are most often solid masses.

Coronal T1 C+ MR shows an enhancing suprasellar mass separate from the pituitary gland below . Note involvement of the optic chiasm . Astrocytoma, IDH-Mutant Coronal T1 C+ MR shows an enhancing suprasellar mass separate from the pituitary gland below . Note involvement of the optic chiasm .

Sagittal T1 C+ MR in a 3-year-old boy with rotary nystagmus and vomiting shows a large suprasellar mass clearly separate from the pituitary gland below . Pilocytic Astrocytoma Sagittal T1 C+ MR in a 3-year-old boy with rotary nystagmus and vomiting shows a large suprasellar mass clearly separate from the pituitary gland below .

Axial T1 C+ FS MR shows an enhancing suprasellar mass involving the optic chiasm and hypothalamus with pial enhancement along the inferior frontal lobe . The lesion also involved the optic nerve. Neurosarcoid Axial T1 C+ FS MR shows an enhancing suprasellar mass involving the optic chiasm and hypothalamus with pial enhancement along the inferior frontal lobe . The lesion also involved the optic nerve.

Coronal T1 C+ FS MR in 22-year-old man with diabetes insipidus shows hydrocephalus and an enhancing sellar/suprasellar mass. Germinoma commonly presents with diabetes insipidus. A macroadenoma often has visual defects. Germinoma Coronal T1 C+ FS MR in 22-year-old man with diabetes insipidus shows hydrocephalus and an enhancing sellar/suprasellar mass. Germinoma commonly presents with diabetes insipidus. A macroadenoma often has visual defects.

Coronal T1 C+ MR shows a diffusely enhancing suprasellar mass that involves the infundibulum. A pituicytoma was diagnosed at resection. These rare tumors are WHO grade 1 and usually arise along the infundibulum or neurohypophysis. (Courtesy A.V. Hasso, MD.) Rare Sellar Region Tumor (Pituicytoma, Granular Cell Tumor, Spindle Cell Oncocytoma) Coronal T1 C+ MR shows a diffusely enhancing suprasellar mass that involves the infundibulum. A pituicytoma was diagnosed at resection. These rare tumors are WHO grade 1 and usually arise along the infundibulum or neurohypophysis. (Courtesy A.V. Hasso, MD.)

Axial T1 C+ FS MR shows a cystic and solid suprasellar enhancing mass . In an adult, craniopharyngiomas may be adamantinomatous or papillary types. Adamantinomatous craniopharyngiomas enhance, calcify, and have cysts. Papillary craniopharyngiomas are commonly solid and enhancing. These are WHO grade 1 tumors. Craniopharyngioma Axial T1 C+ FS MR shows a cystic and solid suprasellar enhancing mass . In an adult, craniopharyngiomas may be adamantinomatous or papillary types. Adamantinomatous craniopharyngiomas enhance, calcify, and have cysts. Papillary craniopharyngiomas are commonly solid and enhancing. These are WHO grade 1 tumors.

Coronal T1 C+ FS MR in 25-year-old woman with visual complaints shows an enhancing suprasellar mass that partially encases the optic chiasm . There is also a parasellar cystic portion of the mass. Pilocytic astrocytomas often present as a solid and cystic cerebellar mass in a child or young adult. These WHO grade 1 tumors are typically T2 hyperintense with variable enhancement. Pilocytic Astrocytoma Coronal T1 C+ FS MR in 25-year-old woman with visual complaints shows an enhancing suprasellar mass that partially encases the optic chiasm . There is also a parasellar cystic portion of the mass. Pilocytic astrocytomas often present as a solid and cystic cerebellar mass in a child or young adult. These WHO grade 1 tumors are typically T2 hyperintense with variable enhancement.

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