Imaging of Sellar and Parasellar Diseases

Dr K Rodgers Radiology Dept Kingston Public Hospital

Overview
Review of Anatomy Physiology Clinical Features Imaging Modalities Differential Diagnosis

Review of Anatomy
Embryology
Derived from two different parts Anterior lobe (Adenohypophysis)- an invagination of the oral ectoderm (Rathkes Pouch) Posterior lobe (Neurohypophysis) protrusion of the neural ectoderm of the diencephalon (Infundibulum) Between the anterior and posterior lobes lies an intermediate lobe Pars intermedia (a potential site for small non-functional Rathkes cysts )

Review of Anatomy
Pituitary gland lies within sella turcica (cup-shaped depression in sphenoid bone) Superiorly Suprasellar cistern with optic chiasm Inferiorly and anteriorly Sphenoid air sinus Laterally Cavernous sinus with Internal carotid arteries and Cranial nerves 3, 4, 6, 5 (1st and 2nd divisions) Connects to hypothalamus via pituitary stalk Hypothalamus makes up floor of anterior part of 3rd ventricle

Review of Anatomy
Sagittal T1

A P C

Anterior pituitary Posterior pituitary Optic chiasm

S
M B CL

Sphenoid air sinus

Mamillary body Brainstem Clivus Stalk

Coronal T1

Review of Anatomy
Characteristics Birth Globular in shape High signal on T1 weighted images Age 6 weeks High signal has diminished in anterior pituitary tissue (now similar signal to brain tissue) Posterior pituitary tissue - retains a bright signal on T1 weighted sequences (Posterior pituitary bright spot - due to the high neurophysin content) Size 3mm - 8mm in height (larger in females than males) increases during adolescence (normal physiological hypertrophy) slight increase in size seen during the sixth decade in females Pregnancy - maximal height post partum of 10mm

Physiology
Anterior pituitary
Gonadotrophins (FSH & LH) Prolactin Growth hormone Adrenocorticotrophin (ACTH) Thyroid stimulating hormone

Posterior pituitary
Oxytocin ADH

Clinical features
Based on location, size and secretory capability Functional tumors Symptoms due to excess hormone release Prolactin (Prolactinoma), ACTH (Cushings Disease), TSH (Thyrotoxicosis), GH (Acromegaly) Usually microadenomas (<10 mm) detected earlier clinically Except Acromegaly which may be detected late Non-functional tumors Symptoms due to compression Visual loss (Bitemporal), Double vision, facial numbness Usually macroadenomas by time of detection Gonadotrophins (FSH, LH)

Imaging modalities - MRI

MRI is modality of choice to image pituitary gland. Standard protocol: Precontrast T1 weighted thin slices (2mm or 3mm) through the sella in coronal and sagittal planes Gadolinium contrast Pituitary gland, stalk and cavernous sinuses enhance Optic chiasm and hypothalamus no enhancement if the blood brain barrier is intact Repeat coronal and sagittal T1 sequences T2 not standard but may be useful to detect cystic changes and haemorrhage

Imaging Modalities - CT
CT useful in patients With contraindications to MRI To detect calcification in or around the sella Ideally MDCT Single-channel axial and helical CT Direct coronal plane with maximal extension of neck in supine or prone position Or axial with thin 1 mm axial contiguous sections 120kV, 200mA, 2-second scanning time Soft tissue algorithm Reformatting in coronal and sagittal planes

Differential Diagnosis
Type
Adenomas
Macro and Micro

Rathkes Cleft cyst Meningioma Craniopharyngioma Hypothalamic/ Optic chiasm gliomas Germinoma Granular cell tumor Langerhan Cell Histiocytosis

Empty Sella Arachnoid cyst Congenital Pituitary Abn

Anatomical Other
Lipoma Hamartoma

Skull Base Tumors

Chordoma Chondrosarcoma

Metastases

Differential Diagnosis
Location

Pituitary Adenomas
Most common mass lesion of the sella and parasellar region Slow-growing benign neoplasms of anterior pituitary Micro (<10mm), Macro (>10mm) Functional versus Non-functional

Pituitary Macroadenoma
Compression symptoms/ Invasion Superiorly - into suprasellar cistern Lateral growth Deformity of the cavernous sinus Invasion into cavernous sinus Inferiorly into the sphenoid producing remodelling of the bone Waisting - pass through the diaphragma sellae

Pituitary Macroadenoma
MR signal Homogeneous or heterogeneous Cystic change and focal areas of haemorrhage Pituitary apoplexy - significant hemorrhage w/ necrosis macroadenoma with areas of high T1 signal representing the haemorrhage

Waisting

Unenhanced sagittal and coronal

Haemorrhage

Pituitary Microadenoma
Confined within the sella Area of lower signal on T1 weighted sequences than the normal pituitary tissue Local remodelling of the floor of the sella and the dorsum IV Gad Enhance less than the normal anterior pituitary tissue Dynamic acquisition in first minute Less vascular on the initial arterial phase Similar vascularity to the normal gland in the next few minutes. Post-op 3 to 4 months before true assessment volume of residual pituitary tissue

Hypointense area post contrast

Unenhanced depression of floor of sella

Post contrast

Rathkes Cleft Cyst

Remnants of squamous epithelium from Rathkes cleft Hyperintense on the T1 weighted sequence If of significant size - hard to distinguish from a cystic craniopharyngioma Wall of a Rathkes cyst shows no more than minimal enhancement No solid enhancing areas No calcification

Large Rathkes cyst

Meningioma
Dural slow growing neoplasms Suprasellar meningiomas Soft tissue mass atop the superior surface of the pituitary Compressing or involving the optic chiasm and nerves From the cavernous sinus Lateral to normal pituitary tissue Encase the cavernous carotid artery Constriction Differentiate from pituitary tumours - do not typically cause vascular constriction

Meeningioma
Dural tail of enhancement along the planum sphenoidale MR features - similar to brain parenchyma and pituitary gland with prominent homogeneous enhancement after contrast

Hyperostosis - most typically the anterior clinoid

process

Craniopharyngioma
Rare epithelial tumours - remnants of the craniopharyngeal duct Commonest lesion of hypothalamic/pituitary region in children Histological subtype Adamantinomatous most common in children Cystic , solid components and calcification Cyst fluid high signal T1 unenhanced High cholesterol content and protein Adherent to surrounding tissue Papillary subtype in adulthood Solid lesions or mixed solid and cystic morphology Do not typically calcify and are less locally infiltrative

Patchy areas of high signal before contrast which represent the cystic components with a high protein/ lipid content.

Hypothalamic/ Optic chiasm gliomas

Suprasellar mass lesions in children commonly Optic chiasm AND hypothalamus usually involved simultaneously Associated with Neurofibromatosis type I Optic nerve involvement Significant cystic component Well-defined suprasellar mass lesions with enhancement and reactive signal change along the optic radiation No calcification

Germinoma
Rare intracranial germ cell tumours Suprasellar or pineal regions MR features Homogeneous, solidly enhancing mass in the hypothalamic region with involvement of the upper aspect of the pituitary stalk Detection of tumour markers human chorionic gonadotrophin (HCG) or alpha fetoprotein (AlphaFP) in the serum/CSF to confirm the diagnosis Absence does not exclude diagnosis biopsy Very sensitive to radiation Disseminate through the CSF spaces - enhancement around ventricular margins

Granular Cell Tumors

Rare lesions in the suprasellar region Arise from the neurohypophysis and/or the pituitary stalk AKA - pituicytomas, infundibulomas or choristomas

Well-defined suprasellar mass related to the pituitary stalk with homogenous enhancement
Asymptomatic/ visual disturbance or headache Benign and slow growing Low recurrence rate after surgery

Langerhan Cell Histiocytosis

Proliferative disorder of the Langerhans cell of the dendritic cell line Most frequently skeletal involvement Intracranial involvement commonly hypothalamo- pituitary axis MR features Thickening of the pituitary stalk with enhancement Absent posterior pituitary bright spot

Hypophysitis
Idiopathic inflammatory lesion of the pituitary gland Lymphocytic hypophysitis, Granulomatous hypophysitis Enlargement of gland - appearance of a sellar mass lesion with suprasellar involvement of the stalk Heterogeneous post contrast with chiasmal distortion of the chiasm Lymphocytic type Classically females at end of pregnancy or the post-partum period with endocrine dysfunction Xanthomatous hypophysitis Least common Distinctly cystic appearance Intrasellar cyst without suprasellar extension or involvement of the stalk

Empty Sella
Only CSF with no visible pituitary tissue Visible pituitary stalk extends into the floor of the sella Due to Previously documented pituitary/hypothalamic pathology or treatment Surgery, radiotherapy, hypophysitis, Sheehans syndrome or pituitary apoplexy) Incidental (Primary empty sella) Women > Men Intracranial hypertension, obesity, visual disturbance and spontaneous CSF leaks Endocrine problems

Prolapsed optic chiasm

Arachnoid Cysts
Benign, congenital CSF-containing cysts arising within the arachnoid membrane Suprasellar region MR features Same signal as CSF on all MR imaging sequences No enhancement after contrast No calcification

Marked elevation of the hypothalamus and stretching the pituitary stalk

Elevation of the right side of the chiasm by the cyst. No cyst wall is evident and the pituitary tissue itself is normal.

Congenital Pituitary Abnormalities

Congenital hypopituitarism May be due to anatomic abnormalities Ectopic High signal area in median eminence Absent pituitary stalk Hypoplasia of anterior pituitary tissue Abnormalities of midline structures (septum pellucidum, corpus callosum etc)

Small pituitary fossa containing a reduced volume of anterior pituitary tissue. The stalk cannot be seen and the posterior pituitary bright spot (arrow) is lying in an ectopic location within the hypothalamus.

Incidentals
Lipoma - Suprasellar cistern MR High T1 signal mass adjacent to normal hypothalamic and pituitary structures FatSat - obliterate the signal from the mass Hamartoma - Tuber cinereum of the hypothalamus Composed of well differentiated neurones and glial cells Associated with central precocious puberty, gelastic (laughing) seizures and sometimes developmental delay MR Pedunculated rounded mass hanging from the hypothalamus Isointense to grey matter of the brain No enhancement Surgical resection if refractory seizures

Lipoma

High signal mass lying just below the hypothalamus and behind the pituitary stalk in the suprasellar cistern. The pituitary tissue and stalk are normal.

Non-enhancing mass visible arising from the undersurface of the hypothalamus and lying behind the pituitary stalk

Skull Base Tumors

Chordoma Remnants of the primitive notochord Centrally located, expansile masses arising from the clivus High signal on T2 weighted images Bony destruction on CT Chondrosarcomas Malignant mesenchymal tumours Similar appearance - but just lateral to the clivus at the site of the petroclival synchondrosis Not possible to distinguish both radiologically

Bony destruction of clivus. Preservation of sella.

Axial T2

Axial T1

Typical bubbly high T2 signal with involvement of the right side of the pituitary fossa , the Rt cavernous sinus and extends into the Rt middle cranial fossa.

Metastases
Uncommon - diffuse malignancy Breast and lung Diffuse enlargement of the gland with thickening of the stalk in a patient with known malignancy

Other
Carotid Arteries Aneurysm Ectasia

Cavernous Sinus
Schwannoma Inflammation Car-Cav Fistula

Tumour

Typical features

Pituitary macroadenoma Enlarged sella turcica, strong enhancement, sometimes haemorrhage Rathke's cleft cyst T1-hyperintense on MRI, smooth peripheral enhancement

Meningioma

Broad dural base, enhancement along planum sphenoidale

Hyperostosis, blistering of sphenoid sinus Crangiopharyngioma Optic glioma

Germ cell tumours

Calcification, cysts, nodular enhancement Thickening of chiasm, spread along optic pathways
Located in midline, intense enhancement; can be synchronous with pineal germinomas

Tumor
Tuber cinerum

Typical Features
Grey matter isointense on T1 weighting and T2 hamartoma hyperintense

Chordoma

Bone destruction on CT, heterogeneous signal and enhancement on MRI

Chondrosarcoma

Bone destruction and calcification on CT, T2 hyperintense on MRI

THANK YOU

References
The Radiology Assistant Sella Turcica and Parasellar region http://www.radiologyassistant.nl/en/485d7745cc720 Pituitary Adenoma Imaging http://emedicine.medscape.com/article/343207-overview Radiology of the Pituitary http://www.endotext.org/neuroendo/neuroendo4/neuroe ndoframe4.htm Imaging Pituitary Gland Tumors http://eradiology.bidmc.harvard.edu/LearningLab/central/ Varshney.pdf