Walter Kucharczyk and Marieke Hazewinkel
Radiology department of the University of Toronto, Canada and the Radiology department
the Medical Centre Alkmaar, the Netherlands
Publicationdate August 10, 2008
This review is based on a presentation given
by Walter Kucharczyka and was adapted for
the Radiology Assistant by Marieke
Hazewinkel.
In this review a systematic anatomic
approach to differential diagnosis of a sellar
or parasellar mass is described.
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Anatomic Approach to Differential Diagnosis
1. First identify the pituitary gland and
sella turcica.
2. Then determine the epicenter of the
lesion and whether it is in the sella or
above, below or lateral to the sella.
3. If it is in the sella, determine whether or
not the sella is enlarged.
4. Once the location of the mass is clear,
analyze the signal intensity patterns: is
the lesion cystic or solid?
5. Does it contain any abnormal vessels?
6. Are there any calcifications? And so on.
7. Finally establish a Differential Diagnosis.
Pituitary gland
On a coronal section through the brain the
reference structure is the pituitary gland
which lies in the sella turcica.
It is usually larger in females than in males
in females the superior border tends to be
convex, whereas in males it is usually
concave.
The most common abnormalities that arise in
the pituitary gland are pituitary adenoma,
Rathke's cleft cyst and craniopharyngioma.
Pituitary stalk
The next structure to identify is the pituitary
stalk.
This is a vertically oriented structure which
connects the pituitary gland to the brain.
It is thinner at the bottom and thicker at the
top.
Embryologically, it is also derived from
Rathke's cleft epithelium and therefore the
pathologies, which can arise in the pituitary
gland can also arise in the stalk.
There are a few unusual things to be
considered in children, such as germinomas
and eosinophilic granulomas.
In adults metastases and occasionally
lymphoma can arise in the pituitary stalk.
Optic chiasm
Another major structure in the suprasellar
cistern is the optic chiasm.
It is an extension of the brain and looks like
the number 8 lying on its side.
It is glial tissue therefore the most common
tumors to originate here are gliomas.
In the US and Europe another frequent
pathology in this region is demyelinating
disease particularly multiple sclerosis.
This can also be associated with some
swelling of the optic chiasm.
Hypothalamus
Further cephalad lies the base of the brain,
which at this location is the hypothalamus.
Anatomically the hypothalamus forms the
lateral walls and floor of the third ventricle.
The most common pathologies to arise here
are gliomas in children hamartomas,
germinomas and eosinophilic granuloma.
Carotid artery
A very important structure in this area is the
internal carotid artery.
It runs a complex anatomic course as it
passes through the skull base shaped like an
S on lateral views.
It passes through the cavernous sinus.
The segment cranial to this is known as the
supracavernous segment.
This bifurcates into the anterior cerebral
artery, which passes cranially to the optic
chiasm, and the middle cerebral artery, which
runs laterally.
Aneurysms and ectasias are pathologies that
can arise here.
One must also be aware of congenital
variations in the course of the internal carotid
Sometimes it is very medially positioned and
can actually lie in the midline.
Cavernous sinus
The cavernous sinus is a paired complex of
venous channels.
In the lateral wall of the sinus run nerve III
(oculomotorius), IV (trochlearis), V1 and V2
(trigeminus).
The sixth cranial nerve (abducens) runs more
medially and is located caudal to the carotid
artery.
The most common pathologies occurring in
the cavernous sinus include schwannomas
arising from the cranial nerves and
inflammation, which can lead to thrombosis.
This is known as cavernous sinus
thrombophlebitis.
Carotidcavernous fistulas are fistulous
communications between the carotid artery
and the veins of the cavernous sinus.
Meninges
The meninges cover the cavernous sinus.
They are thicker laterally and superiorly than
medially and inferiorly.
The most common tumor to arise from the
meninges is of course the meningioma.
Dural metastasis is the second most common
tumor to arise here.
Also inflammatory pathologies occur in the
basal meninges the most common infection
being tuberculous meningitis.
Of the noninfectious inflammatory
pathologies sarcoidosis is the commonest.
Sphenoid sinus
Inferior to the pituitary gland lies the
sphenoid sinus.
This structure contains air and is lined by
mucosa and bone.
Posterior to the sphenoid sinus lies the clivus
(not shown on this coronal section through
the brain).
Pathology that arises in this area includes
carcinomas arising from the mucosa of the
sphenoid sinus squamous cell carcinoma
and adenoid cystic carcinoma are the most
common.
Chordomas arise in the clivus and
chondrosarcomas and osteosarcomas also
occur in this area.
Metastases can occur anywhere.
Bacterial or fungal inflammatory processes in
the sphenoid sinus can spread intracranially
via the cavernous sinus.
Pituitary Microadenoma
Pituitary Macroadenoma
By definition, pituitary macroadenomas are
adenomas over 10mm in size.
They tend to be soft, solid lesions, often with
areas of necrosis or hemorrhage as they get
bigger.
As they grow, they first expand the sella
turcica and then grow upwards.
In this example of a pituitary macroadenoma
there is suprasellar extension with elevation
and compression of the optic chiasm.
Because they are soft tumors, they usually
indent at the diaphragma sellae, giving them
a 'snowman' configuration.
This is one feature that can help distinguish
between a pituitary macroadenoma and a
meningioma.
Another feature which can help differentiate
them is enlargement of the sella turcica this
generally only occurs with pituitary
macroadenomas that originate in the sella.
The usefulness of observing the inclination of
the diaphragmatic leaflets was referred to
earlier.
On the T2weighted images on the right you
can see that the leaflets are displaced
upwards by this macroadenoma which
started in the sella and is growing upwards.
A lesion originating above the sella and
growing downwards would push the leaflets
in the other direction (this can be seen with
meningiomas for example).
Usually the diagnosis of a macroadenoma is
straightforward.
Sometimes a meningioma can give a similar
appearance.
On the left an example of a meningioma.
Note there is no diaphragmatic constriction
and there is uniform enhancement after the
administration of intravenous gadolinium
which is typical of meningioma.
At medical school they teach you that a rare
manifestation of a common lesion is more
likely than a rare abnormality.
Since pituitary adenomas are the most
common lesions of the skull base, it is
prudent to always include them in the
differential diagnosis if you can not identify a
normal pituitary gland when confronted with
a mass in this region.
This patient presented with nasal obstruction.
She went to an ENT specialist who saw a
large endonasal mass and she was referred
to the neurosurgeon for planned major skull
base resection.
The neurosurgeon had seen something
similar before, and checked her prolactin
level.
This was 4000 (25 or less is normal).
Endonasal biopsy revealed prolactinoma.
After treatment with bromocriptine the mass
shrunk down and no surgery was necessary.
Rathke Cleft Cyst
1. Rapid arterial flow (eg. large blood
vessel).
2. No cellular tissue (eg. cyst).
3. No blood supply (eg. infarcted mass).
Craniopharyngioma
Craniopharyngioma is the third of the three
pathologies derived from Rathke's cleft
epithelium.
Technically these are benign tumors, but
unlike Rathke's cleft cysts, they have thick
walls and are locally invasive.
Macroscopically, it is a complex mass with
multiple nodules at the base of the brain,
sinuating along the fissures.
Often, it can not be completely resected.
The picture on the right shows a thickwalled
cyst as part of the craniopharyngioma.
Coronal images of the same mass.
And axial images.
Unenhanced CT shows the calcifications more
clearly.
After intravenous contrast the total extent of
the lesion and its cystic components are
much less evident.
Meningioma
Aneurysm
This is an important case to keep in mind.
This patient is a woman in her late forties,
who presented to her family doctor with
galactorrhea.
The family doctor did a number of tests,
including a determination of her prolactin
level.
This was about 150 (25 or less is normal).
Thinking the patient had a pituitary adenoma,
the family doctor ordered this CT scan.
It is easy to get tunnel vision when reporting
on a scan like this as a radiologist when the
clinical information includes
hyperprolactinemia and galactorrhea.
Of course your first thought is a pituitary
adenoma.
If you look at the location of the lesion
however (partially in the sella turcica and
partially in the cavernous sinus), there are
other possibilities, including a meningioma or
an aneurysm.
The radiologist reported this as a pituitary
adenoma, and the patient was treated with
bromocriptine.
The bromocriptine had no effect, and the
patient went to a neurosurgeon for a surgical
opinion.
The neurosurgeon ordered this MRI.
The lesion partly in the right cavernous sinus
and partly in the sella turcica is
predominantly black on this T1weighted
image.
In general there are three things that are
black on MRI: air, bone and rapid blood flow.
In this case it is black due to rapid blood flow
in a carotid aneurysm.
This is the corresponding angiogram.
Obviously, this is not a lesion to be operated
on transsphenoidally!
This is an example of a partially thrombosed
aneurysm in the suprasellar cistern.
The patent lumen is black on these T1
weighted images.
It is surrounded by clot of different ages
arranged in layers reaching from the lumen
to the wall.
It resembles an onion cut in half.
On the left an autopsy specimen.
You can see that this patient suffered a
massive intraventricular and subarachnoid
hemorrhage.
The layers of bloodclot are very nicely
reflected in the MR images.
Aneurysm vs Meningioma
Angiogram of the same patient.
It demonstrates that the flow in the
aneurysm is not laminar, but that it swirls,
gradually filling the lumen with contrast.
Hamartoma
Hamartomas are masses of dysplastic tissue
found almost exclusively in young children.
One of the most common locations is the
floor of the third ventricle.
This is a pathology specimen showing a small
nodule hanging in the suprasellar cistern.
They are benign lesions, but patients do
succumb to them because of the bad
location.
Hamartoma (red arrow) posterior to the
enhancing pituitary gland and stalk.
Hypothalamic and Chiasm Glioma
Optic nerve glioma in a patient with
neurofibromatosis
Further forward at the level of the orbits the
optic nerve is abnormal on both sides.
On these axial images you can see the optic
nerves and chiasm enhance after the
administration of intravenous gadolinium.
The way a patient is normally positioned,
slices through the nerves themselves are not
obtained.
These slices can be used to make oblique
images along the axis of the nerves.
With these images as a result.
Note the enhancement of the nerve after
intravenous contrast with sparing of the
meninges.
Approximately 25% of optic nerve gliomas do
not enhance, so a lack of enhancement
should not prevent you from making the
diagnosis.
This is another example of a rightsided optic
nerve glioma with enhancement after
gadolinium.
Note the normal pituitary gland and stalk.
Germinoma
Germinoma (Courtesy of Dr. Susan Blaser)
Chordoma
Chondromas are the most common lesions of
the clivus, also a favored location for
metastases and chondrosarcomas.
This patient has a normal pituitary gland.
Posterior to this is a large, fungating mass
positioned at the level of the clivus.
The CT shows some calcifications in this
area.
The differential diagnosis for this mass would
be chondroma or chondrosarcoma.
Chordomas tend to occur in the midline,
whereas chondrosarcomas tend to occur off
the midline.
Metastases
1. First identify the pituitary gland and
sella turcica.
2. Then determine the epicenter of the
lesion and whether it is in the sella or
above, below or lateral to the sella.
3. If it is in the sella, determine whether or
not the sella is enlarged.
4. Once the location of the mass is clear,
analyze the signal intensity patterns: is
the lesion cystic or solid?
5. Does it contain any abnormal vessels?
6. Are there any calcifications? And so on.
7. Finally establish a Differential Diagnosis.