Imaging of the sella Javier Villanueva-Meyer Assistant Professor, - PDF document

1/25/20 Imaging of the sella Javier Villanueva-Meyer Assistant Professor, Neuroradiology UCSF Radiology and Biomedical Imaging 1 Outline • Unknown cases • Anatomy • MRI review • Common (and uncommon) pathology • Case review 2 2 1

1/25/20 Case 1 3 Case 2 Time 4 2

1/25/20 Case 3 5 Case 4 6 3

1/25/20 Case 5 7 Pituitary gland - structure 8 8 4

1/25/20 Dura • 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 Capero A. Neurosurg 2008 9 9 Anatomy 1. Anterior pituitary 14. Anterior commissure 2. Posterior pituitary 15. Midbrain 3. Infundibulum 16. Interpeduncular cistern 4. Hypophyseal cistern 17. Basilar artery 5. Suprasellar cistern 18. Dorsum sellae 14 6. Optic chiasm 19. Floor of pituitary fossa 13 12 22 7 1011 7. Anterior cerebral artery 20 .Sphenoid sinus 6 9 8 21 8. Tuber cinereum 21. Planum sphenoidale 5 15 3 4 23 9. Mamillary body 22. Lamina terminalis 16 1 2 18 17 10. Optic recess cistern 19 11. Infundibular recess 23. Prepontine cistern 20 12. Lamina terminalis 13. Third ventricle 10 10 5

1/25/20 1. Normal Anatomy Meningioma, glioma, H&N Planum Sphenoidale/ Olfactory Groove 11 1. Normal Anatomy Meningioma Tuberculum Sellae 12 6

1/25/20 1. Normal Anatomy Meningioma Dorsum Sellae 13 1. Normal Anatomy Chordoma, Metastases, Clivus Chondrosarcoma, NPC 14 7

1/25/20 1. Normal Anatomy Adenoma, Rathke’s Cyst, craniopharyngioma Sella 15 1. Normal Anatomy Glioma Optic chiasm 16 8

1/25/20 1. Normal Anatomy Hypothalamic Hamartoma/ Hypothalamus/ Glioma Tuber cinereum 17 1. Normal Anatomy Tectum Tectal Glioma 18 9

1/25/20 1. Normal Anatomy Pineoblastoma, Pineocytoma, Pineal Gland Germ Cell Tumor, Pineal Cyst 19 1. Normal Anatomy Corpus Callosum GBM, Lymphoma, Demyelinating 20 10

1/25/20 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 21 Normal MRI of the sella 22 22 11

1/25/20 Normal MRI of the sella 23 Normal MRI of the sella 24 12

1/25/20 Dynamic MRI 0 sec 45 sec • Onset: ~35 sec 90 sec • Peak: 1.2 - 2.2 min • Washout: 2.7 - 5 min 25 25 Dynamic MRI 45 sec 90 sec 135 sec Dynamic enhancement, higher time resolution, but noisier Estimated 10% increase in sensitivity Bartynski W. Am J Neuroradiol 1997 26 26 13

1/25/20 Microadenoma 27 27 Macroadenoma • Mild to avid enhancement • Rarely hypoenhancing (thyrotropin secreting) • Look for enhancing gland (preserved surgically) 28 28 14

1/25/20 Macroadenoma: cavernous invasion • 6-10% of adenomas • Clinical symptoms late • Biologically more aggressive tumors • Suspect when prolactin >1000 ng/dL • Medial sinus has only 1 layer of dura 29 29 Macroadenoma: cavernous invasion 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 30 30 15

1/25/20 Macroadenoma: cavernous invasion Best signs of NO involvement • Involvement < 1/4 circumference • Gland between tumor and cavernous sinus • Medial venous compartment preserved • Medial to medial intercarotid line Cottier J-P. Radiology 2000 31 31 Macroadenoma: cavernous invasion 32 32 16

1/25/20 Macroadenoma: clival invasion 33 33 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 34 17

1/25/20 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 35 Rathke’s cleft cysts by imaging Two types 2/3 1/3 • T1 dark, T2 • T1 bright, T2 bright variable • Fluid like • “Machine oil” CSF cyst • More often symptomatic 36 36 18

1/25/20 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 37 Cystic adenoma • Surrounded by pituitary gland • More frequently off midline (PRL) • Variable signal intensity • Evolve over time if hemorrhagic • May bloom on GRE 38 38 19

1/25/20 Cystic adenoma vs Rathke’s cleft cyst T2 dark nodule is specific for RCC Park M. Am J Neuroradiol 2015 39 39 Meningioma 40 20

1/25/20 Craniopharyngioma - papillary 41 41 Craniopharyngioma - adamantinomatous 42 42 21

1/25/20 Metastasis 43 43 Apoplexy 44 44 22

1/25/20 Hypophysitis - checkpoint inhibitor 45 45 Aneurysm 46 23

1/25/20 Diabetes insipidus 47 47 Intracranial hypotension 48 48 24

1/25/20 Hypothalamic hamartoma 49 Pituitary enlargement in hypothyroidism • Pituitary hyperplasia in primary hypothyroidism • Enlarged in up to 70%, most with TSH 100 >uIU/mL • Decrease after treatment Khawaja NM. Endocr Pract 2006 50 50 25

1/25/20 Ectopic posterior pituitary 51 51 Incidentals… Hoang JK. J Am Coll Radiol 2018 52 52 26

1/25/20 Case 1 Ectopic posterior pituitary 53 Case 2 Hypophysitis Time 54 27

1/25/20 Case 3 Pituitary abscess 55 Case 4 Hypothalamic hamartoma 56 28

1/25/20 Case 5 Aneurysm 57 Outline • Unknown cases • Anatomy • MRI review • Common (and uncommon) pathology • Case review 58 58 29

1/25/20 THANK YOU!! javier.villanueva-meyer@ucsf.edu 59 30