Suprasellar Mass, General



Suprasellar Mass, General


Anne G. Osborn, MD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Pituitary Macroadenoma


  • Meningioma


  • Saccular Aneurysm


  • Craniopharyngioma


  • Pilocytic Astrocytoma


Less Common



  • Dilated Third Ventricle


  • Arachnoid Cyst


  • Neurocysticercosis


  • Rathke Cleft Cyst


  • Neurosarcoid


  • Langerhans Cell Histiocytosis


  • Germinoma


  • Dermoid Cyst


  • Lipoma


Rare but Important



  • Lymphocytic Hypophysitis


  • Tuber Cinereum Hamartoma


  • Epidermoid Cyst


  • Pituicytoma


  • Diffuse Astrocytoma, Low Grade


  • Pilomyxoid Astrocytoma


  • Ectopic Neurohypophysis


  • Metastasis


  • Lymphoma, Metastatic


  • Leukemia


  • Cavernous Malformation


  • Tuberculoma


  • Pituitary Abscess


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Is mass arising from pituitary or other site?


  • Does it mostly involve infundibular stalk?


  • Is patient adult or child?


Helpful Clues for Common Diagnoses



  • Most common diagnoses (“big five”) account for > 75% of all suprasellar masses


  • Pituitary Macroadenoma



    • Most common of all suprasellar masses = suprasellar extension of macroadenoma


    • Gland, mass can’t be separated


    • Cystic, hemorrhagic changes common


    • Mass is the pituitary gland


  • Meningioma



    • Arises from diaphragma sellae


    • Thin black line (diaphragma sellae) separates mass from pituitary


    • “Dural tail sign”



      • Not pathognomonic but highly suggestive


      • Signal intensity following contrast usually > tumor itself


  • Saccular Aneurysm



    • Most arise from circle of Willis


    • Are usually slightly eccentric, not midline


    • Signal intensity may be mixed



      • Partial/complete thrombosis common


      • Complex/disturbed flow may cause spin dephasing


      • Look for phase artifact


    • Occasionally fusiform aneurysm/ectasia of basilar artery may project into suprasellar cistern


  • Craniopharyngioma



    • Most common suprasellar mass in child


    • Adamantinomatous subtype


    • Imaging



      • 90% Ca++, 90% cystic


      • 90% enhance (rim ± nodule)


    • Second peak in middle-aged adults



      • Papillary subtype


      • Solid > cystic; Ca++ uncommon


  • Pilocytic Astrocytoma



    • Second most common suprasellar mass in children (rare in adults)


    • Hypothalamus/optic pathways


    • Pilocytic > > pilomyxoid type (see below)


Helpful Clues for Less Common Diagnoses



  • Dilated Third Ventricle



    • Most common “cystic” suprasellar mass


    • Third ventricle enlarged secondary to obstructive hydrocephalus


  • Arachnoid Cyst



    • Elevates, displaces third ventricle


  • Neurocysticercosis



    • Suprasellar cistern, sylvian fissures common sites


    • Variable size cysts, enhancement


    • Reactive meningeal changes may be striking (e.g., stalk thickening, vascular encasement)


  • Rathke Cleft Cyst



    • Look for intracystic nodule


    • Pituitary displaced by mass


  • Neurosarcoid



    • Thickened stalk may be only sign



    • Look for dural-based masses


  • Langerhans Cell Histiocytosis



    • Thickened stalk, child with DI


  • Germinoma



    • Stalk ± gland


    • Can be only site but look for pineal mass


  • Dermoid Cyst



    • Fat-like ± droplets (ruptured)


  • Lipoma



    • Fatty mass stuck on hypothalamus


    • Use fat-saturated T1WI


Helpful Clues for Rare Diagnoses



  • Lymphocytic Hypophysitis



    • Thick, nontapering stalk ± pituitary mass


    • Diabetes insipidus common


    • Often occurs in peripartum females


  • Tuber Cinereum Hamartoma



    • Clinical presentation helpful (gelastic seizures; male with precocious puberty)


    • Can be “collar button” or “sessile”


    • Between infundibulum (anteriorly), mammillary bodies (posteriorly)


    • Signal intensity like cortex


    • Does not enhance


  • Pituicytoma



    • Low grade (WHO I) glial neoplasm of infundibulum or neurohypophysis


    • M > F, most patients 40-60 years


    • Hypopituitarism, visual disturbances


    • Well-demarcated, homogeneously enhancing infundibular mass


  • Diffuse Astrocytoma, Low Grade



    • Infiltrating mass difficult to distinguish from pilocytic astrocytoma (PA)


  • Pilomyxoid Astrocytoma



    • Rare, more aggressive PA variant


    • Infant/young child with bulky H-shaped suprasellar mass


    • Often hemorrhages (PA, low grade do not)


  • Metastasis



    • Gland ± stalk mass in patient with known primary


  • Lymphoma, Metastatic



    • Destructive, infiltrative mass engulfs gland, stalk


  • Leukemia



    • Gland/stalk + sinus mass clues


  • Cavernous Malformation



    • “Popcorn ball” mass


    • Third ventricle, optic chiasm rare sites


  • Tuberculoma



    • TB meningitis > > frank tuberculoma in suprasellar cistern


    • Focal mass w/ring enhancement common


    • If caseating, mass is hypointense on T2WI


    • If noncaseating, mass generally hyperintense on T2WI


  • Pituitary Abscess



    • Very rare but potentially life-threatening


    • May resemble pituitary apoplexy at imaging



      • Cystic-appearing intrasellar mass with suprasellar extension


      • Hypodense on NECT


      • Hyperintense on T2WI


      • Rim-enhancing






Image Gallery









Sagittal T1 C+ FS MR shows a pituitary macroadenoma image. The pituitary gland cannot be seen separate from the mass. The mass is the gland, which is diffusely enlarged by the tumor.






Sagittal T1 C+ MR shows a classic suprasellar meningioma arising from the diaphragma sellae image, which clearly separates the mass from the normal pituitary below image. Note dural “tails” image.







(Left) Sagittal T1WI MR shows a large, mixed signal intensity, suprasellar mass image. Laminated clot of different ages gives mass an “onion skin” appearance. Note residual patent lumen image. (Right) Sagittal T1WI MR shows a craniopharyngioma image with variable T1 shortening within the multiloculated cystic components. The pituitary gland image is clearly distinct from the mass.

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Suprasellar Mass, General

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