[PDF] - Imaging of the sella Javier Villanueva-Meyer Assistant Professor, PDF Document

SLIDE 1

1/25/20 1

Imaging of the sella

Javier Villanueva-Meyer Assistant Professor, Neuroradiology UCSF Radiology and Biomedical Imaging 1

2

Outline

Unknown cases
Anatomy
MRI review
Common (and uncommon) pathology
Case review

2

SLIDE 2

1/25/20 2

Case 1

3

Case 2

Time

4

SLIDE 3

1/25/20 3

Case 3

5

Case 4

6

SLIDE 4

1/25/20 4

Case 5

7

8

Pituitary gland - structure

8

SLIDE 5

1/25/20 5

9

Dura

Capero A. Neurosurg 2008

Meningeal and periosteal layers
Continuous with dura along planum sphenoidale and clvus
Thin single layer along medial cavernous sinus
Double layer along lateral cavernous sinus

9

10

Anatomy

1. Anterior pituitary
2. Posterior pituitary
3. Infundibulum
4. Hypophyseal cistern
5. Suprasellar cistern
6. Optic chiasm
7. Anterior cerebral artery
8. Tuber cinereum
9. Mamillary body
10. Optic recess
11. Infundibular recess
12. Lamina terminalis
13. Third ventricle
14. Anterior commissure
15. Midbrain
16. Interpeduncular cistern
17. Basilar artery
18. Dorsum sellae
19. Floor of pituitary fossa

20 .Sphenoid sinus

21. Planum sphenoidale
22. Lamina terminalis

cistern

23. Prepontine cistern

1 2 3 4 5 6 7 8 9 1011 12 13 14 15 16 17 18 19 20 21 22 23

10

SLIDE 6

1/25/20 6

1. Normal Anatomy

Planum Sphenoidale/ Olfactory Groove

Meningioma, glioma, H&N

11

1. Normal Anatomy

Tuberculum Sellae

Meningioma

12

SLIDE 7

1/25/20 7

1. Normal Anatomy

Dorsum Sellae

Meningioma

13

1. Normal Anatomy

Clivus Chordoma, Metastases, Chondrosarcoma, NPC

14

SLIDE 8

1/25/20 8

1. Normal Anatomy

Sella Adenoma, Rathke’s Cyst, craniopharyngioma

15

1. Normal Anatomy

Optic chiasm

Glioma

16

SLIDE 9

1/25/20 9

1. Normal Anatomy

Hypothalamus/ Tuber cinereum Hypothalamic Hamartoma/ Glioma

17

1. Normal Anatomy

Tectum Tectal Glioma

18

SLIDE 10

1/25/20 10

1. Normal Anatomy

Pineal Gland Pineoblastoma, Pineocytoma, Germ Cell Tumor, Pineal Cyst

19

1. Normal Anatomy

Corpus Callosum GBM, Lymphoma, Demyelinating

20

SLIDE 11

1/25/20 11

21

UCSF sella MRI protocol

Sagittal & coronal pregad T1 - 10 minutes (TR=600ms, TE=min, NEX=3, 2.7 mm no skip)
Coronal fatsat T2 FSE - 4 minutes (TR=3000ms,TE=102ms, ETL=16, NEX=3, 2.0 mm no skip)
Dynamic gad T1- 45 second intervals (TR=600ms, TE=17 ms, ETL=8, NEX=2, 2 mm no skip)
Sagittal & coronal gad T1 - 10 minutes (TR=800ms,TE=min,NEX=3, 2.7 mm no skip)

21

22

Normal MRI of the sella

22

SLIDE 12

1/25/20 12

Normal MRI of the sella

23

Normal MRI of the sella

24

SLIDE 13

1/25/20 13

25

Dynamic MRI

Onset: ~35 sec
Peak: 1.2 - 2.2 min
Washout: 2.7 - 5 min

0 sec 45 sec 90 sec

25

26

Dynamic MRI

45 sec 135 sec 90 sec

Dynamic enhancement, higher time resolution, but noisier Estimated 10% increase in sensitivity

Bartynski W. Am J Neuroradiol 1997

26

SLIDE 14

1/25/20 14

27

Microadenoma

27

28

Macroadenoma

Mild to avid enhancement
Rarely hypoenhancing (thyrotropin secreting)
Look for enhancing gland (preserved surgically)

28

SLIDE 15

1/25/20 15

29

Macroadenoma: cavernous invasion

6-10% of adenomas
Biologically more aggressive tumors
Medial sinus has only 1 layer of dura
Clinical symptoms late
Suspect when prolactin >1000 ng/dL

29

30

Best signs of involvement

Involvement > 2/3 circumference (PPV 100%)
Carotid sulcus venous compartment (PPV 95%)
Lateral to lateral intercarotid line (PPV 85%)

Cottier J-P. Radiology 2000

Macroadenoma: cavernous invasion

30

SLIDE 16

1/25/20 16

31

Cottier J-P. Radiology 2000

Best signs of NO involvement

Involvement < 1/4 circumference
Gland between tumor and cavernous sinus
Medial venous compartment preserved
Medial to medial intercarotid line

Macroadenoma: cavernous invasion

31

32

Macroadenoma: cavernous invasion

32

SLIDE 17

1/25/20 17

33

Macroadenoma: clival invasion

33

34

Rathke’s cleft cyst

Incidental (13-22%) or symptomatic
Non-neoplastic, single cell layered cyst arising from remnants of embryonic

Rathke’s cleft

Natural history is slow enlargement over time

34

SLIDE 18

1/25/20 18

35

Rathke’s cleft cyst

Well-defined round or ovoid, thin rim of enhancement
Intrasellar (40% and/or suprasellar (60%)
Between anterior and intermediate lobes (pars intermedia)
Stalk midline (typically)

35

36

Rathke’s cleft cysts by imaging

Two types

T1 bright, T2

variable

“Machine oil”

cyst

More often

symptomatic

2/3 1/3

T1 dark, T2

bright

Fluid like

CSF

36

SLIDE 19

1/25/20 19

37

Rathke’s cleft cysts: useful diagnostic features

Arise out of pars intermedia = midline or near midline
No displacement of stalk
Anterior to stalk if suprasellar
“Simple” single intensity

37

38

Cystic adenoma

Surrounded by

pituitary gland

More frequently off

midline (PRL)

Variable signal

intensity

Evolve over time if

hemorrhagic

May bloom on GRE

38

SLIDE 20

1/25/20 20

39

Cystic adenoma vs Rathke’s cleft cyst

Park M. Am J Neuroradiol 2015

T2 dark nodule is specific for RCC

39

Meningioma

40

SLIDE 21

1/25/20 21

41

Craniopharyngioma - papillary

41

42

Craniopharyngioma - adamantinomatous

42

SLIDE 22

1/25/20 22

43

Metastasis

43

44

Apoplexy

44

SLIDE 23

1/25/20 23

45

Hypophysitis - checkpoint inhibitor

45

Aneurysm

46

SLIDE 24

1/25/20 24

47

Diabetes insipidus

47

48

Intracranial hypotension

48

SLIDE 25

1/25/20 25

Hypothalamic hamartoma

49

50

Pituitary enlargement in hypothyroidism

Khawaja NM. Endocr Pract 2006

Pituitary hyperplasia

in primary hypothyroidism

Enlarged in up to

70%, most with TSH 100 >uIU/mL

Decrease after

treatment

50

SLIDE 26

1/25/20 26

51

Ectopic posterior pituitary

51

52

Incidentals…

Hoang JK. J Am Coll Radiol 2018

52

SLIDE 27

1/25/20 27

Case 1

Ectopic posterior pituitary

53

Case 2

Time

Hypophysitis

54

SLIDE 28

1/25/20 28

Case 3

Pituitary abscess

55

Case 4

Hypothalamic hamartoma

56

SLIDE 29

1/25/20 29

Case 5

Aneurysm

57

58

Outline

Unknown cases
Anatomy
MRI review
Common (and uncommon) pathology
Case review

58

SLIDE 30

1/25/20 30

javier.villanueva-meyer@ucsf.edu

THANK YOU!!

59