This document discusses craniopharyngioma, a benign brain tumor that typically arises in the sellar/suprasellar region. There are two pathological types - adamantinomatous (seen in children) and papillary (seen in adults). Adamantinomatous tumors are often large with prominent cysts, calcification, and vivid enhancement on imaging. Papillary tumors tend to be more solid with fewer small cysts and less calcification. Treatment involves surgical resection with radiotherapy for incomplete resections, and adamantinomatous tumors have a higher recurrence rate than papillary tumors.

1. Neuro Radiology -
Craniopharyngioma
Dr.Roopchand.PS
Senior Resident Neurology

2. Introduction:
• Benign (WHO grade I) neoplasms which typically
arise in the sellar / suprasellar region.
• Account for ~ 1 - 5% of primary brain tumours.
• Can occur anywhere from floor of the third
ventricle, to the pituitary gland.
• Two pathological types and they differ in
appearance, epidemiology and prognosis.
o adamantinomatous (paediatric)
o papillary (adult)
o mixed: ~ 15%, but share imaging and prognosis similar to
adamantinomatous

3. Epidemiology:
• Bimodal distribution:
• First peak between the ages of 10 - 14 years
o Adamantinomatous type.
• Second peak in young to middle-aged adults
o Papillary type
• Similar incidence in males and females.

4. Clinical presentation:
• Headaches and raised ICP
• Visual symptoms
o 20% of children
o 80% adults
• Hormonal imbalances
o short stature and delayed puberty in children
o decreased libido
o amenorrhoea
o diabetes insipidus
• Behavioural change due to frontal or temporal
extension.

5. Pathology:
• Arises from the Rathke’s cleft.
• This histological appearances of the two subtypes
are different.
• Adamantinomatous:
o In children
o Reticular epithelial cells which have appearances
reminiscent of the enamel pulp of developing teeth.
o single or multiple cysts filled with thick oily fluid high in
protein, blood products, and/or cholesterol, creating the
so called "machinery oil".
o "Wet keratin nodules" are a characteristic histological
feature.
o Calcification is usually present : ~ 90%

6. • Papillary:
o Seen almost exclusively in adults
o Formed of masses of metaplastic squamous cells .
o "Wet keratin" is absent.
o Cysts do form, but these are less of a feature, and the
tumour is more solid.
o Calcification is uncommon or even rare

7. Radiographic features:
• Significant suprasellar component (95%),
• involving both the suprasellar and intrasellar spaces
(75%).
• Purely suprasellar (20%),
• Purely intrasellar location is quite uncommon (<5%).
• Larger tumours can extend in all directions, frequently
distorting the optic chiasm, or compressing the midbrain
with resulting obstructive hydrocephalus.
• Occasionallycan appear as intraventricular,
homogeneous, soft-tissue masses without calcification
(papillary sub type). The third ventricle is
a particularly common location.
• Rare / ectopic locations include: nasopharynx, posterior
fossa, extension down the cervical spine.

8. Adamantinomatous:
• Lobulated contour as a result of usually multiple
cystic lesions.
• Solid components are present.
o Form a relatively minor component of the mass,
• Enhance vividly on both CT and MRI.
• Calcification is very common, but this is only true of
the adamantinomatous subtype (90% are
calcified)
• Predilection to be large, extending superiorly into
the third ventricle, and encasing vessels, and even
being adherent to adjacent structures.

9. • CT
• cysts
o typically large and a dominant feature
o near CSF density
• solid component
o soft tissue density
o vivid enhancement
• calcification
o seen in 90%
o typically stippled and often peripheral in location

12. • MRI
• cysts: variable but ~80% are mostly or partly T2
hyperintense
• solid component
o T1: iso to lightly hypointense to brain
o T1 C+: vivid enhancement
o T2: variable / mixed
• calcification
o difficult to appreciate on conventional imaging
o susceptible sequences may better demonstrate calcification
• MR angiography: may demonstrate displacement
of the A1 segment of the anterior cerebral artery
• MR spectroscopy: cyst contents may show a broad
lipid spectrum, with an otherwise flat baseline 6

14. T1
T1C

16. Papillary :
• Papillary craniopharyngiomas tend to be more
spherical in outline and usually lack the prominent
cystic component.
• Most are either solid or contain a few smaller cysts.
• Calcification is uncommon or even rare in the
papillary subtype

17. • CT
• cysts
o small and not a major feature
o near CSF density
• solid component
o soft tissue density
o vivid enhancement
• calcification
o uncommon - rare

19. MRI:
• cysts
o when present they are variable in signal
o 85% T1 hypointense
• solid component
o T1: iso to lightly hypointense to brain
o T1 C+: vivid enhancement
o T2: variable / mixed
• MR spectroscopy: cyst contents does not show a
broad lipid spectrum as they are filled with water
fluid

20. T1

21. T1C

22. T2

23. • Treatment is usually surgical with radiotherapy
especially useful for incomplete resection.
• Benign local recurrence is seen in up to a third of
patients.
o papillary has a much lower recurrence rate than adamantinomatous
• Differentials
o Rathke’s cleft cyst.
o Pituitary macroadenoma
o Intracranial terratoma.