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Thick Infundibular Stalk 98b49a22-13ba-4173-aa24-695a146107da
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318f80ab-6abb-4067-a809-2ebdaa5a30c9 Kalen Riley, MD, MBA
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f184750a-90b4-47a7-907b-23b05d70357a Chang Yueh Ho, MD
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5cff4116-3654-4b3a-bb75-5ebe0b8c9850 Anne G. Osborn, MD, FACR
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Brain 90b33505-5ed8-449e-b6a3-bceb64eeefa5 22 01/19/23 Thick Infundibular Stalk Brain, Differential Diagnosis, Sella/Juxtasellar, Pineal Region, Anatomically Based Differentials, Thick Infundibular Stalk Thick Infundibular Stalk | STATdx Thick Infundibular Stalk DDX true
Brain
Differential Diagnosis
Sella/Juxtasellar, Pineal Region
Anatomically Based Differentials
Thick Infundibular Stalk

title: "Thick Infundibular Stalk" docid: "98b49a22-13ba-4173-aa24-695a146107da" authors:

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  • key: "f184750a-90b4-47a7-907b-23b05d70357a" value: "Chang Yueh Ho, MD"
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  • "Brain"
  • "Differential Diagnosis"
  • "Sella/Juxtasellar, Pineal Region"
  • "Anatomically Based Differentials"
  • "Thick Infundibular Stalk"

ESSENTIAL INFORMATION

  • Key Differential Diagnosis Issues

    • Appearance of normal stalk - Tapers from top (at tuber cinereum) to bottom (pituitary gland) - ≤ 2 mm in diameter
    • Thick stalk - > 2 mm in diameter - Loss of normal top to bottom tapering
    • Patient age extremely important in differential diagnosis of thick stalk - Child: Histiocytosis, germinoma - Adult: Neurosarcoidosis, hypophysitis, metastasis, lymphoma

  • Helpful Clues for Common Diagnoses

    • Neurosarcoid - Isolated stalk lesion uncommon - Adults > > children - Enhancing, lobular or infiltrative mass
    • Germinoma - Early detection before becoming large, lobular mass - May be primary in stalk/hypothalamus - Often presents with diabetes insipidus, absent posterior "bright spot"
    • Langerhans Cell Histiocytosis - Calvarium > brain parenchyma, meninges - Infundibulum/hypothalamus = most common CNS site - Children > adults - Absent pituitary "bright spot" common - Thick, hyperintense, enhancing stalk

  • Helpful Clues for Less Common Diagnoses

    • Basilar Meningitis - "Stalkitis" usually part of generalized pia-subarachnoid space infection - Isolated stalk infection rare
    • Lymphoma - Can be primary CNS or metastatic - Enhancing mass along stalk ± pituitary gland, cavernous sinus &/or hypothalamus - Diffusion restriction is characteristic
    • Lymphocytic Hypophysitis - Thick, enhancing stalk ± pituitary mass - May be autoimmune, inflammatory, granulomatous, IgG4 disease or drug related (i.e., ipilimumab)
    • Ectopic Neurohypophysis - Failure of neurohypophysis descent from hypothalamus - T1-hyperintense lesion from hypothalamus through stalk - Associated with septo-optic dysplasia

  • Helpful Clues for Rare Diagnoses

    • Metastasis**(to Stalk/Pituitary)** - Look for other lesions, infiltration of adjacent structures
    • Pituicytoma - Low-grade glial tumor arising from pituicytes in neurohypophysis and stalk; TTF1 expression - Posterior pituitary "bright spot" often absent - Intense, solid enhancement
    • Leukemia - Chronic or acute myelogenous leukemia, typically with known diagnosis

References

Selected References

  1. Moszczyńska E et al: Pituitary stalk thickening in patients under 18 years of age - the most common causes and diagnostic procedures. Pediatr Endocrinol Diabetes Metab. 28(3):213-27, 2022
  2. Devuyst F et al: Central diabetes insipidus and pituitary stalk thickening in adults: distinction of neoplastic from non-neoplastic lesions. Eur J Endocrinol. 181(3):95-105, 2020
  3. Catford S et al: Pituitary stalk lesions: systematic review and clinical guidance. Clin Endocrinol (Oxf). 85(4):507-21, 2016
  4. Wijetilleka S et al: Cranial diabetes insipidus with pituitary stalk lesions. QJM. 109(11):703-8, 2016

Images

Selected Images

Axial T1 C+ MR shows intense, lobular enhancement in the suprasellar cistern and thickening of the pituitary stalk in a patient with sarcoid. Neurosarcoid may involve any part of the CNS, including the meninges, cranial nerves, brain parenchyma, &/or the pituitary axis. Systemic disease is typically present. Neurosarcoid Axial T1 C+ MR shows intense, lobular enhancement in the suprasellar cistern and thickening of the pituitary stalk in a patient with sarcoid. Neurosarcoid may involve any part of the CNS, including the meninges, cranial nerves, brain parenchyma, &/or the pituitary axis. Systemic disease is typically present.

Axial T1 C+ MR shows intense, lobular enhancement in the suprasellar cistern and thickening of the pituitary stalk in a patient with sarcoid. Neurosarcoid may involve any part of the CNS, including the meninges, cranial nerves, brain parenchyma, &/or the pituitary axis. Systemic disease is typically present. Neurosarcoid Axial T1 C+ MR shows intense, lobular enhancement in the suprasellar cistern and thickening of the pituitary stalk in a patient with sarcoid. Neurosarcoid may involve any part of the CNS, including the meninges, cranial nerves, brain parenchyma, &/or the pituitary axis. Systemic disease is typically present.

Sagittal T1 C+ MR shows thickening of the pituitary stalk with involvement of the pituitary gland. This was a germinoma at surgery in a child presenting with hypopituitarism. Germinoma Sagittal T1 C+ MR shows thickening of the pituitary stalk with involvement of the pituitary gland. This was a germinoma at surgery in a child presenting with hypopituitarism.

Sagittal T1 C+ FS MR shows a thickened, enhancing pituitary stalk in a child with Langerhans cell histiocytosis (LCH). There is typically a lack of the posterior pituitary "bright spot." Pay attention for additional enhancing lytic calvarial lesions with a beveled edge appearance classic for LCH. Langerhans Cell Histiocytosis Sagittal T1 C+ FS MR shows a thickened, enhancing pituitary stalk in a child with Langerhans cell histiocytosis (LCH). There is typically a lack of the posterior pituitary "bright spot." Pay attention for additional enhancing lytic calvarial lesions with a beveled edge appearance classic for LCH.

Sagittal T1 C+ FS MR shows diffuse leptomeningeal enhancement of the suprasellar cistern in a patient with pyogenic basilar meningitis. Note the thickened pituitary infundibulum . Basilar Meningitis Sagittal T1 C+ FS MR shows diffuse leptomeningeal enhancement of the suprasellar cistern in a patient with pyogenic basilar meningitis. Note the thickened pituitary infundibulum .

Coronal T1 C+ FS MR shows a thickened, enhancing pituitary stalk in a peripartum female with lymphocytic hypophysitis. Involvement of the anterior pituitary gland is common with pituitary dysfunction. Lymphocytic Hypophysitis Coronal T1 C+ FS MR shows a thickened, enhancing pituitary stalk in a peripartum female with lymphocytic hypophysitis. Involvement of the anterior pituitary gland is common with pituitary dysfunction.

Sagittal T1 MR shows hyperintense thickening of the pituitary stalk with absence of the normal posterior pituitary "bright spot," consistent with ectopic neurohypophysis. Ectopic Neurohypophysis Sagittal T1 MR shows hyperintense thickening of the pituitary stalk with absence of the normal posterior pituitary "bright spot," consistent with ectopic neurohypophysis.

Sagittal T1 C+ MR shows an enhancing mass along the pituitary stalk. This was a pituicytoma, a rare, low-grade glial tumor arising from the pituicytes within the neurohypophysis. Pituicytoma Sagittal T1 C+ MR shows an enhancing mass along the pituitary stalk. This was a pituicytoma, a rare, low-grade glial tumor arising from the pituicytes within the neurohypophysis.

Sagittal T1 C+ MR shows diffuse leptomeningeal enhancement along the brainstem and cerebellar folia . In addition, there is thickening of the pituitary infundibulum . Leukemic infiltration of the pituitary stalk is rare and typically in the setting of known disease with CNS findings. Leukemia Sagittal T1 C+ MR shows diffuse leptomeningeal enhancement along the brainstem and cerebellar folia . In addition, there is thickening of the pituitary infundibulum . Leukemic infiltration of the pituitary stalk is rare and typically in the setting of known disease with CNS findings.

Additional Images

Sagittal T1 C+ MR shows intense enhancement in the suprasellar cistern, particularly with thickening of the stalk . Furthermore, there is abnormal enhancement involving the pial surface and parenchyma of the frontal lobes in this patient with neurosarcoidosis. Neurosarcoid Sagittal T1 C+ MR shows intense enhancement in the suprasellar cistern, particularly with thickening of the stalk . Furthermore, there is abnormal enhancement involving the pial surface and parenchyma of the frontal lobes in this patient with neurosarcoidosis.

Sagittal T1 C+ FS MR shows a thickened, enhancing pituitary stalk in a child with the classic presentation of diabetes insipidus. Pay attention for additional enhancing lytic lesions in the calvarium with beveled edges classic for LCH. Langerhans Cell Histiocytosis Sagittal T1 C+ FS MR shows a thickened, enhancing pituitary stalk in a child with the classic presentation of diabetes insipidus. Pay attention for additional enhancing lytic lesions in the calvarium with beveled edges classic for LCH.

Sagittal T1 MR shows a hyperintense nodule along the pituitary stalk. Along with the absence of the posterior pituitary "bright spot," this is consistent with an ectopic neurohypophysis. This can be seen along the stalk but is most commonly located in the hypothalamus. Ectopic Neurohypophysis Sagittal T1 MR shows a hyperintense nodule along the pituitary stalk. Along with the absence of the posterior pituitary "bright spot," this is consistent with an ectopic neurohypophysis. This can be seen along the stalk but is most commonly located in the hypothalamus.

Coronal CECT in a patient with mild diabetes insipidus (DI) and known leukemia shows thickened, enhancing infundibulum . Sinus and salivary gland lesions were also present. Leukemia Coronal CECT in a patient with mild diabetes insipidus (DI) and known leukemia shows thickened, enhancing infundibulum . Sinus and salivary gland lesions were also present.

Sagittal T1 C+ MR shows an enlarged pituitary gland . Preoperative diagnosis was adenoma. History of DI is more suggestive of hypophysitis, sarcoid, etc. Lymphocytic Hypophysitis Sagittal T1 C+ MR shows an enlarged pituitary gland . Preoperative diagnosis was adenoma. History of DI is more suggestive of hypophysitis, sarcoid, etc.

Sagittal T1 C+ MR shows thickened stalk , dural-based masses , and pituitary gland infiltration . Lymphoma Sagittal T1 C+ MR shows thickened stalk , dural-based masses , and pituitary gland infiltration .

Sagittal T1 C+ MR shows a diffusely thickened, intensely enhancing pituitary stalk in an adult with known sarcoidosis and DI. This was the only intracranial lesion. Neurosarcoid Sagittal T1 C+ MR shows a diffusely thickened, intensely enhancing pituitary stalk in an adult with known sarcoidosis and DI. This was the only intracranial lesion.

Sagittal T1 C+ MR in a 13-year-old girl with central DI shows an enhancing, suprasellar mass involving the infundibulum and extending into the hypothalamus/anterior 3rd ventricle. Germinoma Sagittal T1 C+ MR in a 13-year-old girl with central DI shows an enhancing, suprasellar mass involving the infundibulum and extending into the hypothalamus/anterior 3rd ventricle.

Sagittal T1 C+ MR in a patient with coccidioidomycosis meningitis shows diffuse thickening and enhancement along the infundibular stalk and hypothalamus . Basilar Meningitis Sagittal T1 C+ MR in a patient with coccidioidomycosis meningitis shows diffuse thickening and enhancement along the infundibular stalk and hypothalamus .

Sagittal T1 C+ MR in a child with known Langerhans cell histiocytosis and central DI shows a thickened, rounded, enhancing infundibular stalk . This was the only intracranial lesion. Langerhans Cell Histiocytosis Sagittal T1 C+ MR in a child with known Langerhans cell histiocytosis and central DI shows a thickened, rounded, enhancing infundibular stalk . This was the only intracranial lesion.

Sagittal T1 C+ MR in a middle-aged man presenting with DI shows a thickened, infundibular/hypothalamic, enhancing mass. Preoperative diagnosis was granulomatous disease. Biopsy showed LH. Lymphocytic Hypophysitis Sagittal T1 C+ MR in a middle-aged man presenting with DI shows a thickened, infundibular/hypothalamic, enhancing mass. Preoperative diagnosis was granulomatous disease. Biopsy showed LH.

Sagittal T1 C+ MR in a patient with DI and widespread systemic metastases shows an enhancing mass infiltrating pituitary and thickening infundibulum . This was the only intracranial lesion. Metastasis (to Stalk/Pituitary) Sagittal T1 C+ MR in a patient with DI and widespread systemic metastases shows an enhancing mass infiltrating pituitary and thickening infundibulum . This was the only intracranial lesion.

Sagittal T1 C+ MR in a child with growth failure shows bulbous enlargement of the infundibulum , small pituitary gland , and absent "bright spot." Ectopic Neurohypophysis Sagittal T1 C+ MR in a child with growth failure shows bulbous enlargement of the infundibulum , small pituitary gland , and absent "bright spot."

Sagittal T1 C+ MR in a 22-year-old woman with delayed growth and hypopituitarism for 6 years shows an intensely enhancing mass in the infundibular stalk , extending into the hypothalamus. Pituicytoma Sagittal T1 C+ MR in a 22-year-old woman with delayed growth and hypopituitarism for 6 years shows an intensely enhancing mass in the infundibular stalk , extending into the hypothalamus.

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