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    Atlas

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    Kolea Hanganu
    This document provides an overview of the anatomy and pathologies of the sella and parasellar region. It discusses: 1) Normal anatomy of the pituitary gland, sella turcica, and surrounding structures on MRI. 2) Common pathologies like pituitary adenomas, craniopharyngiomas, meningiomas, cysts and metastases. It provides imaging features to differentiate these lesions. 3) Important considerations for imaging the region like using multiplanar MRI with contrast and dynamic imaging to better identify microadenomas.

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    Atlas

    Uploaded by

    Kolea Hanganu
    271 views56 pages
    This document provides an overview of the anatomy and pathologies of the sella and parasellar region. It discusses: 1) Normal anatomy of the pituitary gland, sella turcica, and surrounding structures on MRI. 2) Common pathologies like pituitary adenomas, craniopharyngiomas, meningiomas, cysts and metastases. It provides imaging features to differentiate these lesions. 3) Important considerations for imaging the region like using multiplanar MRI with contrast and dynamic imaging to better identify microadenomas.

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    Atlas

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    This document provides an overview of the anatomy and pathologies of the sella and parasellar region. It discusses: 1) Normal anatomy of the pituitary gland, sella turcica, and surrounding structures on MRI. 2) Common pathologies like pituitary adenomas, craniopharyngiomas, meningiomas, cysts and metastases. It provides imaging features to differentiate these lesions. 3) Important considerations for imaging the region like using multiplanar MRI with contrast and dynamic imaging to better identify microadenomas.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    271 views56 pages

    Atlas

    Uploaded by

    Kolea Hanganu
    This document provides an overview of the anatomy and pathologies of the sella and parasellar region. It discusses: 1) Normal anatomy of the pituitary gland, sella turcica, and surrounding structures on MRI. 2) Common pathologies like pituitary adenomas, craniopharyngiomas, meningiomas, cysts and metastases. It provides imaging features to differentiate these lesions. 3) Important considerations for imaging the region like using multiplanar MRI with contrast and dynamic imaging to better identify microadenomas.

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    The Sella and Parasellar Region

    Anatomic and Pathologic


    Considerations:
    A Practical Approach

    Philip Chapman, MD
    Assistant Professor
    University of Alabama,
    Birmingham
    The Sella and Parasellar Region
    Outline

    • Imaging Techniques
    • Normal Anatomy
    • Differential Diagnosis
    – Sella
    – Suprasellar
    – Infundibulum
    Recommended Imaging Techniques
    MRI Imaging
    • Multiplanar:
    • Sagittal and Coronal
    • Small FOV 16-18 cm
    • 3mm
    • T1W, T2W
    • Post T1W + FS
    • Dynamic enhanced for
    pituitary lesions
    Sella: Normal Anatomy

    Pituitary Gland
    • Anterior Lobe (75%)
    • Pars Intermedia
    • Posterior Lobe (25%)
    • Infundibulum
    Pituitary: Normal Anatomy
    Anterior Lobe
    Lateral
    • PRL (10-30%)
    • GH (50%)
    Midline
    • ACTH (10-30%)
    • TSH (5%)
    • FSH/LH (10%)

    • Location of adenomas
    parallels the distribution
    Pars intermedia
    Sella: Normal Anatomy

    Pituitary Bright Spot

    The secretary granules


    carrying vasopression and
    oxytocin appear as the
    “bright spot” of the posterior
    lobe of the pituitary gland on
    T1-weighted unenhanced
    (MRI).
    Pituitary: Normal Anatomy
    Posterior Lobe
    • Infundibulum
    • Pituicytes (glial)
    • Axons
    • Vasopressin (ADH)
    • Oxytocin
    Ectopic Posterior Pituitary
    Parasellar Region: Normal Anatomy
    Parasellar Structures
    • Cavernous Sinus
    • Cranial Nerves
    • III, IV, V1, V2, VI
    • Cavernous ICA
    • Optic Chiasm
    • Hypothalamus
    • Sphenoid Sinus
    Parasellar Region: Normal Anatomy
    Parasellar Region: Normal Anatomy
    Bony Structures
    • Planum sphenoidale
    • Tuberculum sellae
    • Sella turcica
    • Dorsum sellae
    ***CT is complementary
    for evaluating central
    skull base lesions:
    • Effects on skull base
    • Calcifications
    Sella and Parasellar Pathology
    Differential Diagnoses
    • Sellar
    • Suprasellar
    • Infundibular
    Sellar Pathology
    Non-neoplastic Lesions
    • Hyperplasia/Hypertrophy (physiologic, end organ failure)
    • Cysts (RCC, pars intermedia cyst)
    • Empty Sella
    Primary Neoplasms
    • Pituitary adenoma (Most common)
    • Craniopharyngioma (Only 5% purely intrasellar)
    • Meningioma (Purely intrasellar rare)
    • Abscess (Rare)
    • Pituitary carcinoma (Extremely rare)
    Metastasis (1%)
    Pituitary Gland Size
    Maximum normal height
    • 6 mm infants and children
    • 8 mm males, postmenopausal females
    • 10 mm young women of childbearing age
    • 12 mm late pregnancy, postpartum females
    • “Elster’s Rule”
    Pituitary
    Hyperplasia/Hypertrophy
    • Must know age, gender!!
    • Physiologic ↑
    • 10-15 mm
    Postpartum lactating ♀
    • Convex upwards 14 mm

    • Strong, uniform
    enhancement
    • Can be indistinguishable
    from:
    • Macroadenoma 21y menstruating ♀ 11 mm

    • Lymphocytic hypophitis
    • Metastasis, lymphoma
    Pituitary
    Hyperplasia/Hypertrophy

    Postpartum lactating ♀
    14 mm
    *** Dynamic imaging may
    help distinguish physiologic
    hyperplasia from
    macroadenoma

    21y menstruating ♀ 11 mm
    Pituitary Gland
    Hyperplasia/Hypertrophy

    Pathologic
    hypertrophy
    • End-organ failure
    - Hypothyroidism
    - Ovarian failure
    • Neuroendocrine
    tumors
    Pituitary hypertrophy secondary to
    untreated hypothyroidism
    “EMPTY” SELLA

    Considered normal variant. Loose association with Pseudotumor Cerebri


    Pituitary Neoplasms
    Adenoma Adenoma type
    • Adenomas comprise the • Prolactinoma 30%-40%
    majority (80%) of pituitary • Null cell 25%
    lesions. • GH 20%
    • ACTH 10%
    • A large percentage of these
    • FSH/LH 10%
    (approximately 75%) are
    functioning and result in • PRL-GH 5%
    endocrine abnormalities. • Mixed, TSH 1-5%
    • Incidental pituitary
    lesions are common
    Sella: Pathology
    Pituitary Microadenoma
    • 10 mm or less
    • 10-20% of autopsies
    • Micro >>> Macro
    • Convex margin
    • Stalk deviation
    • Sella floor thin
    Recommended Imaging Techniques
    Dynamic Imaging
    • Microadenomas
    • 4-5 slices
    • T1 FSE, Turbo SE
    • Image continuously
    after contrast for app 2
    minutes
    • Increases sensitivity for
    small adenomas
    Sella: Pathology
    Dynamic Imaging

    • In essence, the normal


    pituitary gland enhances at a
    faster rate than the
    microadenoma, so that early
    during contrast injection (90
    seconds), the adenoma
    appears as hypointense
    against the backdrop of
    enhancing pituitary tissue.
    • This difference is lost as
    microadenoma gradually
    accumulates contrast (after
    app 2 minutes)

    There is up to a 20% false-negative rate in the detection of microadenomas.


    Sella: Pathology
    Microadenoma
    Dynamic Imaging
    • Increases sensitivity
    • (10-30% seen only on
    dynamic MR)

    There is up to a 20% false-negative rate in the detection of microadenomas.


    Pituitary Microadenoma
    Sella: Rathke Cleft Cyst
    Clinical
    • Intrasellar 40%
    • Suprasellar extent
    60%
    • 3mm – 3cm
    • Most incidental
    • Symptomatic
    Pituitary dysfunction
    Visual change, HA
    Rathke Cleft Cyst: CT
    CT
    • 75% hypodense
    • 25% iso/hyperdense
    • Ca++ rare
    • May be difficult to
    differentiate from
    other benign cysts or
    craniopharyngiomas
    Rathke Cleft Cyst: MR
    Imaging Features
    • Signal varies - cyst
    content
    • 50-60% T1
    hyperintense
    • 30-40% follow CSF
    • 75% intracystic
    nodule
    • +/- rim enhancement
    Rathke Cleft Cyst
    Rathke Cleft Cyst
    Suprasellar Masses: The “Big Five”

    • 75% of all sellar/parasellar masses


    1. Pituitary macroadenoma (35%-50%)
    2. Meningioma
    3. Aneurysm
    10% each
    4. Craniopharyngioma
    5. Astrocytoma (hypothalamic-chiasmatic)
    Suprasellar Differential Diagnosis
    Adult Lesions Pediatric Lesions
    • Pituitary • Craniopharyngioma
    Macroadenoma • Chiasmatic /
    • Meningioma Hypothalamic
    • Aneurysm Glioma
    • Hypothalamic
    Hamartoma
    Suprasellar Masses
    • Is the patient adult or child?
    • Is the mass intra- or extra-axial?
    • If extra-axial, does it arise from pituitary?
    – Can you identify pituitary gland separate from mass?
    – Or is the gland the mass?
    – Does it mostly involve the infundibular stalk?
    • Intra-axial masses arise from
    – Optic chiasm, hypothalamus
    – 3rd ventricle
    • Is the mass cystic or solid?
    – If cystic, is it exactly like CSF?
    Pituitary Macroadenoma
    Clinical / Pathologic
    • Most common
    suprasellar mass (50%)
    • Compressive
    symptoms
    • 10% of intracranial
    tumors
    • > 10mm
    • Enlarged sella turcica
    Suprasellar: Pathology
    Pituitary Adenoma
    Prolactinoma
    • 30%-40% of
    adenomas
    • Female >> Males
    • Galactorrhea
    • Amenorrhea
    • Serum PRL >
    150ng/mL
    • If > 1000ng/mL
    invasion
    Pituitary Macroadenoma: MR
    Imaging Features
    • Isointense GM: T1,
    T2WI
    • “Mass is the pituitary”
    • May have hemorrhage,
    cystic components
    • Figure-eight, snowman
    • Strong but
    heterogeneous
    enhancement
    Pituitary Macroadenoma: MR
    Giant Pituitary Macroadenoma

    4 cm

    Prolactinoma
    Giant Pituitary Macroadenoma
    Cavernous Sinus Invasion
    • Adenomas that involve
    the lateral margins of the
    adenohypophysis may
    grow laterally beyond the
    sellar margin and invade
    the adjacent cavernous
    sinus.
    • 5- 10% of all pituitary
    adenomas involve the
    cavernous sinus and are
    considered to be invasive
    Cavernous Sinus Invasion
    Involvement of the
    cavernous sinus:
    • increases the morbidity
    and mortality associated
    with surgical procedures
    • results in higher rates of
    residual /recurrent tumor
    • may necessitate adjuvant
    radiotherapy or
    suppressive medications
    Pituitary-Cavernous Interface

    Songtao, Qi, et al. Membranous Layers of the Pituitary


    Gland, Operative Neurosurgery, March 2009
    Cavernous Sinus Invasion

    0 1 2

    3 4
    Knosp-Steiner Grading
    Cavernous Sinus Invasion

    Cottier et al Cavernous sinus invasion by pituitary adenoma: MR imaging.


    Radiology. 215(2):463-469, 2000
    • Found the most specific sign of CSI to be partial tumor encasement of
    the intracavernous ICA by 67% of its circumference (positive predictive
    value of 100%)
    • Cavernous sinus invasion could be ruled out with a negative predictive
    value of 100% if the percentage of encasement of the perimeter of
    intracavernous ICA was lower than 25%
    Extrinsic narrowing of the
    carotid artery is rarely
    associated with pituitary
    adenomas and is more
    suggestive of meningiomas
    Invasive Pituitary Macroadenoma
    37 yo male with Prolactinoma
    Infrasellar Extension

    Growth hormone secreting Prolactin secreting


    Plasmacytoma/Myeloma
    Multiple Myeloma Of Clivus

    69 yo with h/o mm 65 yo male with mm


    Prolactinoma Chordoma
    Pituitary Apoplexy
    Clinical Syndrome
    • Acute onset
    • Visual changes
    • Headache
    • Vomiting
    • Meningismus
    • Rapid enlargement of
    Macroadenoma
    secondary to
    hemorrhagic infarction
    • Rare, life threatening
    T1 Shortening in subacute hemorrhage
    Pituitary apoplexy

    21 yr old female with abrupt headache and visual loss


    Pituitary (Tumor) Apoplexy

    Peripheral enhancement may indicate


    acute hemorrhage or infarction
    Macroadenoma with hemorrhage?

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