DISCLOSURES NAVIGATING THE SELLA AND CENTRAL …...NAVIGATING THE SELLA AND CENTRAL SKULL BASE Christopher P. Hess, M.D., Ph.D. RSNA 2013: ESSENTIALS OF NEURO IMAGING DISCLOSURES Research

NAVIGATING THE SELLA AND CENTRAL SKULL BASEChristopher P. Hess, M.D., Ph.D.

RSNA 2013: ESSENTIALS OF NEURO IMAGING

DISCLOSURES

Research Support, General Electric

SLIDES: http://www.radiology.ucsf.edu/research/meetings/rsna


LEARNING OBJECTIVES

• Review general anatomy of the central skull base

• Develop a structured approach to diagnosis for lesions in & around the central skull base

• Recognize findings that require urgent intervention


WE WILL NOT DISCUSS

• SATCHMO

• Juxtasellar lesions

• Exhaustive differentials

• Skull base foramina in detail

X


MESSAGE

important steps for correct diagnosis in & around the central skull base:

Identify lesion originRecognize key imaging features

Evaluate surrounding tissues

3


CSB: Birdseye View


Carotid sulcus

F. rotundum

F. ovale

F. spinosum

Optic canal

CSB: Birdseye View


Temporal

bone

Sphenoid Bone

Occipital Bone

Frontal Bone

CSB: Birdseye View


Clivus

CSB: Birdseye View

Petro-clival fissure

Temporal

bone


Clivus

LSWLSW

Sella GSWGSW

CSB: Birdseye View

Temporal

bone


CSB: Midline Anatomy

S

CSB

SS

Nasal cavity

NP

Planum sphenoidale


STOPS AROUND THE CSB

1

2

3

4

5

1. Planum sphenoidale

2. Sella

3. Clivus

4. Nasopharynx

5. Sphenoid sinus

5


STOPS AROUND THE CSB5#1 - Planum


CASE 1 Progressively worsening visual acuity

T2 T1+


CASE 1 Progressively worsening visual acuity

T1 T1+RSNA 2013: ESSENTIALS OF NEURO IMAGING

CASE 1 Your Diagnosis?

A. Macroadenoma

B. Meningioma

C. Metastatic disease

D. Optic nerve glioma

E. Normal variant



A. Macroadenoma

B. Meningioma

C. Metastatic disease

D. Optic nerve glioma

E. Normal variant


Skull Base Mengioma

Olfactory Groove Planum Sphenoidale Tuberculum Sella Petroclival


Skull Base Mengioma

• Keys to diagnosis:

Sagittal imagesSeparate lesion from pituitary glandDural “tails”

• Primary differential is adenoma

• Stalk effect - hyperprolactinemia

• Main issue is growth in small spaces

• May extend through SB foramina


Curious Features of Meningiomas

Vessel Narrowing Bony Reaction Pneumosinus


STOPS AROUND THE CSB5#2 - Sella


CASE 2 Headache, AMS, Visual Deficits

T1 T1+


CASE 2 Headache, AMS, Visual Deficits

T2 T2*RSNA 2013: ESSENTIALS OF NEURO IMAGING


A. Hemorrhagic adenoma

B. Rathke cleft cyst

C. Craniopharyngioma

D. Meningioma

E. Chordoma



A. Hemorrhagic adenoma

B. Rathke cleft cyst

C. Craniopharyngioma

D. Meningioma

E. Chordoma


Pituitary Adenoma

• Sellar enlargement, growth in 6 directions• Checklist - optic chiasm, hemorrhage, cav sinus• T2 signal similar to gray matter• Larger tumors have more heterogeneous signal

T1+


Diagnostic Key: Where is the Gland?

T1+ T2


Pituitary Apoplexy

• Acute visual deficit• Intratumoral hemorrhage• Blooming on T2*• Hematocrit levels• Hyperdensity on CT


FamineDeath War

The Four Horsemen of the APOCALYPSE

ConquestRSNA 2013: ESSENTIALS OF NEURO IMAGING

MeningiomaRathkeAdenoma Craniopharyngioma

The Four Horsemen of the SELLA


Craniopharyngioma

T1+T2T1


CT Helps to Confirm Calcification

T2T1


Craniopharyngioma

• Mostly suprasellar• May enlarge sella• Mixed solid & cystic• Rule of 9’s:

90% calcify (“eggshell”)90% cystic90% enhance90% suprasellar


Rathke Cleft Cyst: A Histologic Continuum

• Incidental or symptomatic• Typically midline (arise from pars intermedia)• 40% intrasellar, 60% extend suprasellar• Natural history is slow growth

Intracystic Nodule

• T2 hypointense• No enhancement


Two Types of Rathke Cleft Cysts

“Machine Oil” (2/3) “Simple Serous” (1/3)

• T1 hyperintense• T2 variable• More frequently symptomatic

• T1 hypointense• T2 bright• Fluid approximates CSF

vs


STOPS AROUND THE CSB5#3 - Clivus


CASE 3

T1 T2

Diplopia, CN6 Palsy


CASE 3

T1+

Diplopia, CN6 Palsy


CASE 3A. Metastasis

B. Lymphoma

C. Pituitary adenoma

D. Benign osseous lesion

E. Chordoma

Your Diagnosis ?


CASE 3A. Metastasis

B. Lymphoma


D. Benign osseous lesion

E. Chordoma

Your Diagnosis ?


CASE 3 Clival Chordoma

• Derive from primitive notocord• Spheno-occipital synchondrosis• Circumscribed midline tumors• Expansile growth• Physaliphorous cells = high T2• “Honeycomb” enhancement

T2T1RSNA 2013: ESSENTIALS OF NEURO IMAGING

Ecchordosis Physaliphora

T2


• Benign tumor of notochord remants• 2% of autopsies• Asymptomatic• Does not enhance• Clival “pedicle” sometimes present• Recommendation: follow

Ecchordosis Physaliphora


Chondrosarcoma

• Usually off midline (petro-clival synchondrosis)• Tend to be lower grade tumors• Better prognosis than chordoma• High T2 signal = cartilage

T1

T2 T1+


Chondrosarcoma

• Usually off midline (petro-clival synchondrosis)• Tend to be lower grade tumors• Better prognosis than chordoma• High T2 signal = cartilage• Up to 50% have chondroid matrixT1

T2


Distinguishing Imaging Features ?

Chordoma “Thumb”

Sequestrations Chordoma

Chondroid matrixChondrosarcoma

Osseous Matrix


Distinguishing Imaging Features ?

*Yeom et al, AJNR 2013

Higher ADC in Chondrosarcoma*

• ADC 25% higher in chondrosarcoma than chordoma• Lowest ADC in poorly differentiated chordoma

Chordoma “Thumb”


“Arrested” Pneumatization

• Developmental lesion• Nonexpansile• Sclerotic margins• Curvilinear calcification• Intralesional fat


Diabetic with Cranial Neuropathy x Weeks


Skull Base Osteomyelitis

T2 T1



T2 T1+


• Diabetic or immunocompromised

• Headache & cranial neuropathy

• Isolated or contiguous spreadOtitis media & mastoiditisPetrous apicitis

• Key to diagnosis: surrounding inflammatory changes

• Pseudomonas most common



Clival Tumor Mimic

T2 T1 T1+


Fibrous Dysplasia

• Tumor mimic on MRI!• Expansile but shape preserving• Low T2 signal• Variable enhancement• Key to diagnosis is CT


STOPS AROUND THE CSB5

#4 - NasopharynxRSNA 2013: ESSENTIALS OF NEURO IMAGING

CASE 4

T1 T1+

Nasal Congestion, Epistaxis


CASE 4

T2 T1+

Nasal Congestion, Epistaxis


CASE 4A. JNA

B. Lymphoma


D. Chordoma

E. Meningioma

Your Diagnosis?



A. JNA

B. Lymphoma


D. Chordoma

E. Meningioma


Juvenile Nasopharyngeal Angiofibroma

• Benign but aggressive• Adolescent males• Center within posterior nasal cavity• Expansion of the pterygopalatine fossa• Highly vascular - flow voids• Bone destruction


Other NP Lesions Involving the CSB

• Nasophayngeal ca• Sinonasal lymphoma• Rhabdomyosarcoma• Infection


• Nasophayngeal ca• Sinonasal lymphoma• Rhabdomyosarcoma• Infection

Other NP Lesions Involving the CSB


STOPS AROUND THE CSB5#5 - Sphenoid sinus


CASE 5

T1+

Headaches & Hypopituitarism

T2 T2


CASE 5 Headaches & Hypopituitarism

T1 T1+RSNA 2013: ESSENTIALS OF NEURO IMAGING

CASE 5 Headaches & Hypopituitarism



A. Chordoma

B. Sphenoid mucocele

C. Fungal infection

D. ICA pseudoaneurysm

E. Macroadenoma



A. Chordoma

B. Sphenoid mucocele

C. Fungal infection

D. ICA pseudoaneurysm

E. Macroadenoma


ICA Pseudoaneurysm

• Contained arterial rupture from trauma, radiation, or malignancy

• Clinical triad: visual changes, epistaxis, history of facial trauma

• Laminated T1 signal

• Phase artifact from pulsatile flow

• Beware of the low T2 mass!


Multiple Cranial Neuropathies

T2 T1+ T1


Sphenoid Mucocele

T2 T1+


SUMMARY

• Location, location, location

• One imaging modality is often not enough

• Useful imaging features - low T2, effects on bone & surrounding structures, calcification, dural tails, etc

• Be on the alert for mimics - is it an aneurysm?

• Make the diagnosis, then think about management

[email protected]://www.radiology.ucsf.edu/research/meetings/rsna

Thank you!

Documents

DISCLOSURES NAVIGATING THE SELLA AND CENTRAL …...NAVIGATING THE SELLA AND CENTRAL SKULL BASE Christopher P. Hess, M.D., Ph.D. RSNA 2013: ESSENTIALS OF NEURO IMAGING DISCLOSURES Research