Image differential diagnosis of common tumors in sellar area

Four types of large tumors are common in sellar area

1.

2.

3.

4.

(The above are all extra-brain tumors)

Image inspection method

• Ultrasound: worthless

  
  

• X-ray: Plain film-application value has a large limit; DSA-invasive, generally not used

  
  

• CT: plain scan + enhanced + reconstruction, can make a good positioning and qualitative diagnosis

  
  

• MR: Multi-directional, multi-parameter and three-dimensional imaging and functional imaging, accurate positioning, quantification, delimitation, and even qualitative

  
  

Ultrasound: worthless

X-ray: Plain film-application value has a large limit; DSA-invasive, generally not used

CT: plain scan + enhanced + reconstruction, can make a good positioning and qualitative diagnosis

MR: Multi-directional, multi-parameter and three-dimensional imaging and functional imaging, accurate positioning, quantification, delimitation, and even qualitative

(Therefore, CT and MR examinations are usually used, and the diagnosis rate of MRI is higher)

Basic signs

Direct signs:

• Sellar mass (density/signal, structure, morphology)

• Strengthening type and degree

Sellar mass (density/signal, structure, morphology)

Strengthening type and degree

Indirect signs:

• Skull changes

• Brain edema around the tumor (generally no or mild tumors outside the brain)

• Space sign

• Violation of surrounding tissues

Skull changes

Brain edema around the tumor (generally no or mild tumors outside the brain)

Space sign

Violation of surrounding tissues

Specific signs:

• Calcification, bleeding, etc.
  

Calcification, bleeding, etc.

Pituitary macroadenoma

• Pituitary tumors are a group of tumors that occur from the anterior and posterior lobes of the pituitary.
  They are the most common tumors in the sella area; those with a diameter greater than 10mm are macroadenomas of the pituitary gland
  .
  

• The cause is unclear, probable cause: genetic factors, physical and chemical factors and biological factors
  .
  

• Pathology: (1) functional (hormone secreting function): prolactinomas, growth hormone adenoma (oncocytoma); adenoma adrenocorticotropic hormone (basophil adenoma) and the like
  .
  (2) Non-functional: chromophobe cell adenoma
  .
  

• Clinical: Occurs in adults.
  Large adenomas generally have no obvious endocrine manifestations.
  They are often diagnosed or accidentally discovered due to oppressive symptoms (visual impairment, headache, hypopituitarism, etc.
  )
  .
  

• Both CT and MRI are of high value for its positioning and qualitative diagnosis; MRI can clearly show the relationship between tumors and large blood vessels and adjacent structures, which is better than CT
  .
  

• Uneven density/signal, waist sign/snowman sign
  .
  

Pituitary tumors are a group of tumors that occur from the anterior and posterior lobes of the pituitary.
They are the most common tumors in the sella area; those with a diameter greater than 10mm are macroadenomas of the pituitary gland
.

The cause is unclear, probable cause: genetic factors, physical and chemical factors and biological factors
.

Pathology: (1) functional (hormone secreting function): prolactinomas, growth hormone adenoma (oncocytoma); adenoma adrenocorticotropic hormone (basophil adenoma) and the like
.
(2) Non-functional: chromophobe cell adenoma
.

Clinical: Occurs in adults.
Large adenomas generally have no obvious endocrine manifestations.
They are often diagnosed or accidentally discovered due to oppressive symptoms (visual impairment, headache, hypopituitarism, etc.
)
.

Both CT and MRI are of high value for its positioning and qualitative diagnosis; MRI can clearly show the relationship between tumors and large blood vessels and adjacent structures, which is better than CT
.

Uneven density/signal, waist sign/snowman sign
.

A 49-year-old male, with numbness in the extremities for 2 months
.
Occasional dizziness and headache

A type of round solid space-occupying lesions are seen in and on the saddle, the boundary is still clear, the density is not uniform, and the CT value is about 41-58HU
.
The pituitary fossa is enlarged and the saddle back bone is slightly thinner
.

A large mass was seen in the saddle area, with irregular shape and clear borders, with iso-signal on T1WI, and mixed signals on T2WI;

The typical girdle sign and snowman sign can be seen on the sagittal and coronal planes (when adenoma grows upward through the saddle diaphragm, it forms a symmetrical notch due to the restriction of the saddle diaphragm)
.

The lesion is uneven and obviously strengthened
.
The optic chiasm and pituitary stalk move upward under pressure
.

A 20-year-old woman was found to have hemianopia for more than half a year
.
Visual field examination was temporal hemianopia
.

A round mass with uneven density is seen in the sella-suprasella pool
.
The sella is slightly enlarged, the bone in the back of the saddle is thinned, and the suprasellar pool is compressed and narrowed
.

Treatment (comprehensive):

• Surgical resection (fundamental cure)

• Radiation (can control tumor development)

• Drugs (bromocriptine, which has a certain effect on prolactin adenoma and growth hormone cell adenoma)

Surgical resection (fundamental cure)

Radiation (can control tumor development)

Drugs (bromocriptine, which has a certain effect on prolactin adenoma and growth hormone cell adenoma)

Craniopharyngioma

• An embryonic residual tissue tumor developed from the residual epithelial cells of the craniopharyngeal tube formed by the ectodermal leaf
  .
  The most common congenital tumor in the skull
  .
  

• Etiology: Embryo remnant theory-derived from the residual epithelial cells in the process of craniopharyngeal duct degeneration
  .
  

• Pathology: ameloblast type and papillary type
  

• Clinical: It is common in children (developmental disorders, increased intracranial pressure, visual field disorders, etc.
  ), and more common in saddles
  .
  

• Generally, there is no cerebral edema, and hydrocephalus occurs when the interventricular foramen is blocked
  .
  

• CT and MRI positioning and characterization are more accurate, and MRI is better
  .
  

• The density/signal is complex, with many cysts and calcification foci (eggshell-like calcification, CT); the edge or parenchyma of the enhancement is obviously enhanced
  .
  

An embryonic residual tissue tumor developed from the residual epithelial cells of the craniopharyngeal tube formed by the ectodermal leaf
.
The most common congenital tumor in the skull
.

Etiology: Embryo remnant theory-derived from the residual epithelial cells in the process of craniopharyngeal duct degeneration
.

Pathology: ameloblast type and papillary type

Clinical: It is common in children (developmental disorders, increased intracranial pressure, visual field disorders, etc.
), and more common in saddles
.

Generally, there is no cerebral edema, and hydrocephalus occurs when the interventricular foramen is blocked
.

CT and MRI positioning and characterization are more accurate, and MRI is better
.

The density/signal is complex, with many cysts and calcification foci (eggshell-like calcification, CT); the edge or parenchyma of the enhancement is obviously enhanced
.

Male, 2 years old, with double vision impairment

A round cystic mass with long T1 and long T2 signals was seen in the sellar area, and the thickness of the cyst wall was uneven
.

The wall of the sac was ring-shaped reinforcement, and no obvious reinforcement was seen in the sac
.
The lesion occupies the sella, suprasellar cistern, and the anterior part of the third ventricle, with clear edges
.

A round cystic mass was seen in the sellar area with eggshell-like calcification on the cyst wall
.
The mass is pressed down into the sella, up to the level of the third ventricle
.

A 17-year-old male with abnormal language, impaired vision, urinary incontinence, and lethargy for more than 1 month
.

The suprasellar cistern-third ventricle sees a round cystic solid space with a clear boundary, and the inside is dominated by cystic long T1 and long T2 signals, with uniform signals; in addition, multiple nodular solid lesions can be seen on the inferior wall of the cyst , Bulging into the capsule in a papillary shape
.

The solid lesions in the cyst and the cyst wall were obviously strengthened, but the contents of the cyst were not strengthened
.
The optic chiasm is compressed and shifted forward, and the pituitary is visible, but the pituitary stalk is unclear
.
The midbrain structure is shifted back and the midbrain aqueduct is unobstructed
.

The third ventricle was significantly narrowed, and the bilateral lateral ventricles and the fourth ventricle were normal
.
The mass adjacent to the brain parenchyma showed compression changes, the relationship was clear, and there was no sign of brain parenchymal infiltration and edema
.

(Compression on optic chiasm, pituitary stalk, midbrain; no obstructive hydrocephalus)

treatment:

• Surgery is the main thing, try to remove it completely

• Local radiotherapy supplemented after partial resection

• Large cystic single cavity, can be used for internal radiotherapy with isotope 32P

Surgery is the main thing, try to remove it completely

Local radiotherapy supplemented after partial resection

Large cystic single cavity, can be used for internal radiotherapy with isotope 32P

Meningioma

• It is a derivative of arachnoid granular cap cells
  .
  

• Causes: Certain internal environment changes and genetic mutations, traumatic brain injury, radiation exposure, viral infections, and bilateral acoustic neuroma combined accelerate the division of arachnoid cells, which may be an important early stage of cell degeneration
  .
  

• Pathology: It grows in a spherical shape, has a capsule, and has a clear boundary with the brain tissue.
  Hemorrhage or calcification can be seen.
  The blood supply is abundant.
  It is connected to the dura mater with a broad base
  .
  

• Clinical: It is more common in adults, and the incidence of females is about twice that of males
  .
  Mainly symptoms of oppression
  .
  The predominant sites are: parasagittal sinus, falx, convex surface, bromine groove, and sellar tuberosity
  .
  

• MRI is the first choice, CT supplement (whether calcification, bleeding, skull involvement, etc.
  )
  .
  

It is a derivative of arachnoid granular cap cells
.

Causes: Certain internal environment changes and genetic mutations, traumatic brain injury, radiation exposure, viral infections, and bilateral acoustic neuroma combined accelerate the division of arachnoid cells, which may be an important early stage of cell degeneration
.

Pathology: It grows in a spherical shape, has a capsule, and has a clear boundary with the brain tissue.
Hemorrhage or calcification can be seen.
The blood supply is abundant.
It is connected to the dura mater with a broad base
.

Clinical: It is more common in adults, and the incidence of females is about twice that of males
.
Mainly symptoms of oppression
.
The predominant sites are: parasagittal sinus, falx, convex surface, bromine groove, and sellar tuberosity
.

MRI is the first choice, CT supplement (whether calcification, bleeding, skull involvement, etc.
)
.

The density/signal is uniform, there is an envelope, and there may be spotty calcification; the enhancement is uniform, significant enhancement, meningeal tail sign
.

61-year-old female suffers from repeated dizziness for more than 3 years

On the saddle, there is a kind of round, uniform and slightly high-density foci with a CT value of about 47 HU.

The boundary is clear, and a small flaky calcification is seen in it; secondary suprasellar cistern compression with degeneration
.

The mass in the sellar area showed equal T1 and other T2 signals, with uniform signals and clear boundaries
.

The lesion was uniform and significantly enhanced (steamed bun-like), connected to the base of the anterior cranial fossa with a wide base.

In the coronal and sagittal positions, the brain (dura) tail sign is seen;

The mass protrudes into the suprasellar cistern and pushes upward on the optic chiasm.
The posterior edge is adjacent to the pituitary stalk and adjacent to the bilateral internal carotid arteries
.

(Mingeal tail sign: enhanced scan, the thickened dura mater adjacent to the mass shows a narrow band of enhancement, as it moves away from the tumor

And gradually become thinner
.
)

The intracranial arteries walked naturally, the wall was smooth, and there were no signs of focal abnormal stenosis or enlargement
.

Male 62 years old, his right eye was blurred for half a year

A round, slightly high-density mass is seen in the saddle area, the density is relatively uniform, the boundary is clear, and the position is slightly to the right, protruding upward into the suprasellar cistern, and the surrounding bone is not damaged
.

A mass is seen in the base of the anterior cranial fossa and the anterior saddle area, showing equal T1 and other T2 signals.
The signal is uniform and the edges are clear.
The broad base is in contact with the skull base
.

The lesion showed uniform and obvious enhancement (steamed bun-like), with meningeal tail sign; the posterior part of the mass entered the saddle, squeezing the front of the pituitary gland and the optic chiasm, and the pituitary stalk was unclear
.

The A1 segment of the right anterior cerebral artery was completely surrounded by the tumor; the A1 segment of the left anterior cerebral artery was not clearly demarcated from the tumor, but there was no obvious wrapping and progress
.
No abnormal signs were seen in bilateral cavernous sinuses
.

treatment:

• Surgical resection (most effective)

• Patients who cannot be completely resected, postoperative radiotherapy

• Others: hormone therapy, molecular biology therapy, traditional Chinese medicine therapy, etc.
  

Surgical resection (most effective)

Patients who cannot be completely resected, postoperative radiotherapy

Others: hormone therapy, molecular biology therapy, traditional Chinese medicine therapy, etc.

Aneurysm

• Refers to the focal abnormal enlargement of the intracranial artery
  .
  

• Etiology: It is not clear yet.
  Most scholars believe that it is caused by local congenital defects in the wall of the intracranial artery and increased intraluminal pressure.
  Hypertension, cerebral arteriosclerosis and vasculitis are related to the occurrence and development of aneurysms.
  Related
  .
  

• Pathology: Most tumors are connected to the tumor-bearing artery with a pedicle (tumor neck)
  .
  According to the morphology, it is divided into: miliary, cystic, fusiform, intermural (sandwich) or irregular
  .
  Under the microscope, it can be seen that the middle layer of the artery suddenly terminates or disappears at the neck of the aneurysm.
  Most of the fibers in the elastic layer are broken.
  Thick hyalineosis often merges with calcified plaques and forms mural thrombus
  .
  

• Clinical: It is more common in young and middle-aged people
  .
  The tumor is often asymptomatic when it is not ruptured, and some cases may haveSymptoms of epilepsy , headache, cranial nerve compression, and symptoms of cerebral ischemia or cerebral infarction due to thrombosis
  .
  After rupture, it often results in SAH and intracerebral hematoma
  .
  

• DSA-the gold standard, the most reliable, but invasive, and cannot show a fully thrombotic aneurysm, while CT and MRI can show it
  .
  (CTA and MRA can be diagnosed, especially MSCTA has high sensitivity and specificity
  .
  )

• The tumors are mostly round, oval, or irregular; the boundary is clear and sharp
  .
  

Refers to the focal abnormal enlargement of the intracranial artery
.

Etiology: It is not clear yet.
Most scholars believe that it is caused by local congenital defects in the wall of the intracranial artery and increased intraluminal pressure.
Hypertension, cerebral arteriosclerosis and vasculitis are related to the occurrence and development of aneurysms.
Related
.

Pathology: Most tumors are connected to the tumor-bearing artery with a pedicle (tumor neck)
.
According to the morphology, it is divided into: miliary, cystic, fusiform, intermural (sandwich) or irregular
.
Under the microscope, it can be seen that the middle layer of the artery suddenly terminates or disappears at the neck of the aneurysm.
Most of the fibers in the elastic layer are broken.
Thick hyalineosis often merges with calcified plaques and forms mural thrombus
.

Clinical: It is more common in young and middle-aged people
.
The tumor is often asymptomatic when it is not ruptured, and some cases may haveSymptoms of epilepsy , headache, cranial nerve compression, and symptoms of cerebral ischemia or cerebral infarction due to thrombosis
.
After rupture, it often results in SAH and intracerebral hematoma
.

DSA-the gold standard, the most reliable, but invasive, and cannot show a fully thrombotic aneurysm, while CT and MRI can show it
.
(CTA and MRA can be diagnosed, especially MSCTA has high sensitivity and specificity
.
)

The tumors are mostly round, oval, or irregular; the boundary is clear and sharp
.

The imaging findings are related to the presence or absence of thrombus in the tumor cavity:

1.
Without thrombosis: CT scan showed slightly higher density, and enhanced scan showed obvious uniform enhancement
.

2.
Part of the thrombosis: CT enhanced scan, the center and the cyst wall are obviously enhanced-the target sign
.

3.
Complete thrombosis: CT scan showed iso-density, and only the cyst wall was enhanced during enhancement
.

(If there is no thrombosis, there is no signal or low signal on T1WI and T2WI-empty effect; if there is thrombus, there are mixed signals on T1WI and T2WI
.
)

58-year-old female, dizzy, vomiting, a round shape is seen in the right front of the pons

High and low mixed (with thrombus) T1 and T2 signal shadows, with clear and sharp boundaries
.

Obviously uneven enhancement (thrombosis in the tumor)
.
Unclear boundary with basilar artery

Cranial CTA: A local tumor-like protrusion (wide base) at the beginning of the basilar artery without space-occupying effect
.

72 years old female , more than 3 years after being diagnosed with diabetes

A mass of slightly higher density shadows are seen in the upper saddle area, with clear boundaries and uniform density
.

On the upper right side of the saddle, there is a kind of elliptical flowing empty shadow
.

The lesion is obviously enhanced (the thrombus in the tumor is not enhanced), the boundary is clear, and the boundary with the sponge segment of the right internal carotid artery is not clear
.
The size and shape of the pituitary gland were not abnormal
.

treatment:

Surgery: aneurysm neck clipping or ligation, aneurysm isolation, aneurysm wrapping, endovascular interventional therapy 

Non-surgical treatment after rupture and bleeding: prevention of rebleeding, reduction of intracranial pressure, drainage of cerebrospinal fluid (ventricular drainage, lumbar puncture or lumbar cistern drainage), prevention and treatment of cerebral vasospasm

The main points of image identification of common tumors in sellar area

new progress:

• Differentiation of preoperative pituitary adenomas from tumors of non-pituitary origin in sellar area is very important for the development of surgical plans
  .
  CT and MRI can provide clues for the differential diagnosis.
  These clues and differential diagnosis are very important to neurosurgeons.
  They can avoid the embarrassing situation of "transdish approach" tumors that are not completely resected and reduce the occurrence of complications
  .
  

•  MRI-enhanced scan can clearly show the size range, morphological features, corner edges and internal tissues of the lesion in the sellar area
  .
  As long as we fully understand the imaging characteristics of the sellar area and combine the relevant clinical data, a comprehensive and comprehensive analysis will help to further improve the accuracy of the diagnosis
  .
  

•  MRS

Differentiation of preoperative pituitary adenomas from tumors of non-pituitary origin in sellar area is very important for the development of surgical plans
.
CT and MRI can provide clues for the differential diagnosis.
These clues and differential diagnosis are very important to neurosurgeons.
They can avoid the embarrassing situation of "transdish approach" tumors that are not completely resected and reduce the occurrence of complications
.

 MRI-enhanced scan can clearly show the size range, morphological features, corner edges and internal tissues of the lesion in the sellar area
.
As long as we fully understand the imaging characteristics of the sellar area and combine the relevant clinical data, a comprehensive and comprehensive analysis will help to further improve the accuracy of the diagnosis
.

 MRS

Look at the picture to identify tumors

Meningioma: uniform, obvious enhancement, meningeal tail sign

Aneurysm: smooth, empty signal, CTA, MRA

Pituitary macroadenoma: less uniform

Girdle sign, snowman sign

Pituitary gland disappeared