case

1. Approach to sellar and
parasellar masses
Dr YASH SHAH
3rd year resident
Dept. Of radiodiagosis
SBKS MI & RC

2. What is Goal of imaging?
 to determine precisely the location and
characteristics of a sellar mass
 to delineate its relationship to—and
involvement with surrounding structures
 construct a reasonable limited differential
diagnosis to help direct patient
management

3. Ask yourself some questions
 to determine anatomic sublocation is the
first, most important step.
Is the lesion (1) intrasellar, (2) suprasellar, (3)
in the infundibular stalk? Or is it a
combination of these locations?
So what is the key?
"Can I find the pituitary gland separate from
the mass?" If you can't, and the gland is the
mass, the most likely diagnosis is
macroadenoma.

4. If the mass is clearly separate from the
pituitary gland -
meningioma in an adult or
craniopharyngioma in children
 What is the age of the patient?
adult – macroadenoma, meningioma,
aneurysm
prepubescent child - Nonneoplastic pituitary
gland enlargement > tumor
children - opticochiasmatic/hypothalamic
pilocytic astrocytoma & craniopharyngioma

5.  What is Sex of the patient?
young menstruating female and
postpartum women often demonstrate
plump-appearing pituitary glands due to
temporary physiologic hyperplasia.
 Endocrine status of the patient?
-serum prolactine level
-pituitary macroadenomas rarely cause
diabetes insipidus, but it is one of the
most common presenting symptoms of
hypophysitis.

6.  Lastly, consider some specific imaging
findings.
- Is the mass cystic?
- Is it calcified?
- What is the MR signal intensity?
- Does the lesion enhance?
- Does it contain blood products?
- Is it focal or infiltrating?
- Does it enlarge or invade the sella
turcica?

7. CASE :
37 year old female patient

8. T2WI T1WI

9. DWI ADC

10. T2WI FLAIR

11. Coronal T2WI Sagittal T2WI

12. 3D T1WI C+ coronal and sagittal

14. Imaging findings

15. How macroadenoma looks in NECT?

16. CASE –
 9 year old boy presents with
headache,nausea, vomiting, increased
urinary frequency and increased thirst.
 Polyuria
Urine specific gravity - <1.005
Raised serum sodium level
patient underwent NECT
Be a good radiologist

17. So patient advised MRI BRAIN WITH CONTRAST

18. T1WI

19. FLAIR

20. T1 C+

21. Imaging findings?

22. A hypodense mass with peripheral calcification
located in a suprasellar location

23. T1WI
- mass is
Hyperintense.
- The calcifications
seen on CT are
evident as very
small foci along
the rim of the
lesion.

24. FLAIR
-mass is also hyperintense
on FLAIR images

25. T1 C+
- Lesion is
very large and extends
from the sella cephalad
to elevate the corpus
callosum.
- A small
enhancing region
Indicative of a small soft
tissue component Is
seen at the caudad
aspect
of the mass and within
the sella.

26. What are the differentials?
 Pituitary adenoma:
why not? - rare in children. Furthermore, a large cystic component
and calcification would be unusual.
 Rathke’s cleft cyst:
why? - sellar and suprasellar location, cystic
why not? - typically predominantly intrasellar, usually much
smaller than the lesion shown here, do not contain a soft
tissue component, and are not calcified.
 Craniopharyngioma:
why? – age, clinical presentation, location, typically have
both a calcified component and a cyst. (rule of 90)

27. A suprasellar mass in child or
adolescent is considered a
craniopharyngioma until proven
otherwise.
REMEMBER

28. CASE -
 A 50-year-old woman presents with
chronic headache and visual difficulty.

29. T2WI AXIAL

30. T1WI SAGITTAL

31. T1 C+ SAGITTAL

32. T1 C+ CORONAL

33. Imaging findings?

34. T2WI AXIAL
There is a hyperintense
suprasellar mass with
smooth margins.

35. T1WI SAGITTAL
- The mass displaces the
third ventricle posteriorly.
- A sharp margin is seen
between the mass and
the pituitary
gland, which is displaced
inferiorly.

36. T1 C+ SAGITTAL
The mass is
seen to homogeneously
enhance.

37. T1 C+ CORONAL
The mass is
obliterating the suprasellar
cistern and displacing both
optic nerves laterally.

38. What are the differentials?
 ACoM Aneurysm:
why not? - no flow voids. Even thrombosed aneurysm typically
shows a laminar appearance of blood products in various
stages of evolution and also frequently produces pulsation
artifact.
 Optic nerve glioma:
why not? - rounded shape. usually has an oval shape with its
long axis. Furthermore, the optic nerves are seen to be
spared on imaging
 Meningioma:
why? – increased signal intensity on T2WI, homogeneous
enhancement and globoid shape. Female.

39. CASE -
 A 76-year-old man presents with sudden
onset of bitemporal visual field deficit and
headache.

40. NECT AXIAL

41. T2WI AXIAL

42. T1WI AXIAL

43. T1 C+ CORONAL

44. Imaging findings?

45. NECT AXIAL
A slightly hyperdense
mass within
the sella, causing mass
effect on the right
cavernous sinus and
erosion of the right
posterior clinoid process.

46. T2WI AXIAL
The mass is slightly
inhomogeneous and
contains a central
region that is
hyperintense and a
peripheral
region that is slightly
hypointense relative to
gray matter.

47. T1WI AXIAL
The central portion
of the mass is
hyperintense and the
peripheral portion
relatively isointense
to gray matter

48. T1 C+ CORONAL
-Most of the
upper segment of the
central portion of the
mass Is hyperintense;
the remainder of the
mass Is unenhancing.
-A small portion of the
mass extends Into the
suprasellar cistern.
-The floor of the sella is
depressed by the mass

49. What are the differentials?
 Ruptured dermoid cyst:
Why? - region of hyperintense signal on the T1WI, which could
potentially represent fat within a dermoid cyst. sudden onset
of symptoms
why not? – old age. no imaging findings suggestive of rupture
(e.g., hyperintense foci within the CSF space) are present.
And an unruptured dermoid cyst would not be expected to
produce sudden symptom onset.
 Meningioma:
why not? - lack of contrast-enhancement.
mass is indistinguishable from the pituitary gland
 Hemorrhagic pituitary macroadenoma (pituitary
apoplexy) :
why? – large size(>10mm), location, focus of hyperintense
signal in the cephalad portion of the lesion is consistent with
hemorrhage

52. HOPE NOW YOU BECAME
GOOD RADIOLOGIST,
ATLEAST FOR SELLAR AND
PARASELLAR MASSES