it is simple discussion for doctors doing post graduation in radiology. D/D is for proptosis esp. in paediatric age group

1. SUPRASELLAR MASS:
CT SCAN OF A
CHILD
Dr Rekha Khare
MD Radiology

2. CLINICAL PRESENTATION
 A male child of about eight months was brought
by his parents to CT room for head CT scan
 Parents noticed the bulging of left eye for few
weeks
 Vision was poor/ blind left eye
 There was no other constitutional symptoms

3. CLINICAL EXAMINATION
 Apparently child was found normal except
PROPTOSIS Left eye
 Routine laboratory exam were with in normal
limit

4. COMMON CAUSES OF PROPTOSIS
 V_ Vascular (arterio venous malformation)
 E_ Endocrinal ( thyrotoxicosis )
 I_ Infection/ Inflammation
 N_ Neoplasm ( Primary/ Secondary )
( Local/ Intracranial )
VEIN……

5. WHAT TO SEE ON CT SCAN?
 eye ball
 eye muscles ( extra ocular )
 retro bulbar space
 optic nerve
 bony socket
 adjoining paranasal sinus/ nasal cavity
 intracranial tissue

6. PLAIN CT SCAN OF BRAIN

7. CONTD……..

8. CONTD…….

9. CONTD…….

10. CONTD…….

11. CONTD…….

12. CONTD…….

13. CONTD……..

14. CONTD…….

15. CONTD…….

16. CONTD…….

17. CONTD…….

18. CONTD…….

19. CONTRAST ENHANCED CT SCAN

20. CONTD…….

21. CONTD……

22. CONTD……..

23. CONTD…….

24. CONTD……..

25. CONTD………

26. CONTD……..

27. CONTD…….

28. CONTD……..

29. CONTD…….

30. CONTD………

31. CONTD……..

32. CT FINDINGS IN OUR CASE
 An about 22x22mm hypodense globular mass,
highly enhanced slightly heterogeneous in
suprasellar region
 Mass is extending to left frontal lobe and
deepening the floor of sella
 Mass is markedly entering to left orbital fossa
through optic chiasma, encasing optic nerve
sparing extra ocular muscles

33. DIFFERENTIAL DIAGNOSIS
In contrary to adult age most common
suprasellar tumor in child are with
decreasing frequency ……
: Craniopharyngioma
:Chiasmatic/ Hypothalamic low grade
glioma
: Germinoma
: Lesion attributed to langerhans cell
histiocytosis

34. D/D
SUPRA/ PARA/ INTRASELLAR
MASS
Satchmoe : nick name of “Louis Armstrong”
1. S: Sarcoidosis, sellar tumor
2. A: Adenoma, Aneurysm
3. T: Teratoma, Tubercular granuloma
4. C: Craniopharyngioma, Cyst-Rathke’s cleft
5. H: Hemartoma,Hypothalamic glioma
6. Histiocytosis
7. M: Metastasis
8. O: Optic nerve glioma, Germinoma
9. E: Epidermoid, Eosinophilic granuloma

35. CRANIOPHARYNGIMA
Large intra and supra sellar mass with
cystic& enhancing component as well as
calcification in children are virtually
pathognomonic for Craniopharyngioma……
perhaps with only Dermoid in the D/D
**Our case shows no calcification at all

36. PATHOLOGICAL TYPE
 Admantinomatous ….paediatric age group
 Papillary…..Adult age group
 Mixed……15%

37. EPIDEMIOLOGY
 There is Bimodal age presentation with 1st
peak
between 10-14 age almost exclusively of
Admantinomatous type
 2nd
peak young to middle aged mostly papillary
sub type
 Incidence about 6% of all expanding lesion in
childhood

38. CLINICAL SIGNS/ SYMPTOMS
 Increased intracranial tension (headache)
 Endocrine dysfunction (Delayed puberty, short
stature)
 Visual problem

39. RADIOLOGICAL FEATURES
 95% suprasellar, frequently distorting optic
chiasma or compressing mid brain causing
hydrocephalus
 Occasionally intraventricular homogenous soft
tissue mass with calcification commonly at 3rd
ventricle

40. CT SCAN FINDINGS
 Cystic near CSF density
 Soft tissue density vivid enhancement
 Calcification in 90% cases
**calcification is uncommon in papillary
variety

41. CHIASMATIC HYPOTHALAMIC
GLIOMA
 4-8% childhood intracranial tumor, rare in
adults
 Common in first decade less than 1yr
 Male: Female incidence is equal
 20-30% children are associated with
neurofibromatosis
 Progress rapidly

42. CH GLIOMA CONTD…..
 Chiasmatic glioma can involve anything between
optic nerve to visual cortex
 Almost 25% optic pathways gliomas are confined
to optic disc and nerve
 40-75% may involve optic chiasma

43. CLINICAL SIGNS/ SYMPTOMS
 Painless PROPTOSIS
 Hydrocephalus if involving foramen of monro
**HISTOLOGICALLY: Low grade Glioma

44. PITUITARY ADENOMA
 Rarely present in children
 Pituitary micro adenoma: less than 10mm in
size
 Pituitary macro adenoma: more than 10mm
in size expansion of sella is common
 Most pediatric pituitary adenomas present after
the onset of puberty and present with frequent
headaches, changes in visual acuity and, in
females, menstrual dysfunction.
 Most (19/20) were secretory, with prolactinomas
being the most common type.

45. SUPRASELLAR MENINGIOMA
 Benign tumor of meninges usually solid may
contain necrotic/ cystic lesion and calcification
 Frequently invade the sella turcica
 Such tumor can also encase the optic nerve
with in optic canal and fossa orbitalis

46. ARACHNOID CYST AND RATHKE’S
CLEFT CYST
 Rarely in suprasellar region in children
 Clinical symptom:
visual symptom, hydrocephalus,
macrocephaly, pyramidal tract sign, precocious
puberty

47. MISCELLANEOUS LESION
A. Hypothalamic hemartoma:
usually small and asymptomatic presenting
in two decades
Clinical symptom:
hyperactivity syndrome with hyperplasia,
behavior disorder, precocious puberty,
gelastie seizure

48. CONTD…..
 B. Lesion of INFUNDIBULUM:
: Germinoma
: Hypophysitis
: Histiocytosis X

49. SUPRASELLAR GERMINOMA
 20% of all Germ cell tumor
 Hypo intense on T1, Hyper intense on T2 and
extremely intense contrast enhancement
 It can create diagnostic dilemma on imaging ,
can get easily confused with optic/ chiasmatic
glioma.
 If serum and CSF studies for tumor marker are
negative , surgical exploration for biopsy and
histological confirmation helps differentiation

50. FINAL DIAGNOSIS
 Our probable diagnosis:
Suprasellar germinoma OR Chiasmatic
Hypophyseal Glioma
 Patient was sent to advanced center for final
diagnosis and further management
 Unfortunately there was no feed back

51. CONCLUSION
 Paediatric brain tumor have always been a
challenge
 They are heterogeneous set of pathologies
involving different age groups in childhood and
also differ widely from their adult counterparts
as far as adjuvant therapies are concerned
 Unlike Meningioma and Pituitary Adenoma in
adults, Craniopharyngioma, Optic Glioma and
Germinoma form the main lesions in paediatric
age group

52. CONTD…..
 While safe surgery is the Key in most of adult
tumors, Chemo and Radiotherapy are the chief
modality in some of these paediatric tumor like
GERMINOMA and OPTICO- CHIASMATIC
GLIOMA
 As epidemiology and management of these
tumors is different that’s why it requires
dedicated multidisciplinary team approach

53. REFERENCES
1. Differential Diagnosis of suprasellar mass in
children: Warmnth Metz M, Gnekow AK,
Muller H, Solynosi L K.Klin Paediatri 2004
Nov Dec 216(6):323;30
2. Pituitary region mass: Dr Ayush Goel and
Dr Frank Gaillard etal.
Radiopaedia.org/article/Pituitary
3. Sella turcica and parasellar region: Walter
Kucharezyk and Marieke Hazewinkel The
Radiology assistant
4. Cranipharyngioma: Dr Frank Gaillard etal.
Radiopaedia.org/article/craniopharyngioma

54. REF……CONTD.
5. Suprasellar Meningioma_ a case report: MG
Kgoro, A Speclman The south African
Radiographer vol.51 no 2 Nov 2013
6. Pituitary macro adenoma: Dr Henry Knipe and
Yuranga W etal. Radiopaedia.orgt
7. Paediatric Suprasellar Lesion:. CE Deopujari,
Ashish Kumar, VS Karmarkar, NK Biyani,
M Mhatre and NJ shah
Journal of Paediatric Neurosciences 2011 Oct(6
supple): 546-555

55. Thank you
Have a good day