DISCLOSURES NAVIGATING THE SELLA AND CENTRAL …...NAVIGATING THE SELLA AND CENTRAL SKULL BASE...
Transcript of DISCLOSURES NAVIGATING THE SELLA AND CENTRAL …...NAVIGATING THE SELLA AND CENTRAL SKULL BASE...
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
RSNA 2013: ESSENTIALS OF NEURO IMAGING
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
RSNA 2013: ESSENTIALS OF NEURO IMAGING
WE WILL NOT DISCUSS
• SATCHMO
• Juxtasellar lesions
• Exhaustive differentials
• Skull base foramina in detail
X
RSNA 2013: ESSENTIALS OF NEURO IMAGING
MESSAGE
important steps for correct diagnosis in & around the central skull base:
Identify lesion originRecognize key imaging features
Evaluate surrounding tissues
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CSB: Birdseye View
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Carotid sulcus
F. rotundum
F. ovale
F. spinosum
Optic canal
CSB: Birdseye View
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Temporal
bone
Sphenoid Bone
Occipital Bone
Frontal Bone
CSB: Birdseye View
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Clivus
CSB: Birdseye View
Petro-clival fissure
Temporal
bone
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Clivus
LSWLSW
Sella GSWGSW
CSB: Birdseye View
Temporal
bone
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CSB: Midline Anatomy
S
CSB
SS
Nasal cavity
NP
Planum sphenoidale
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STOPS AROUND THE CSB
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2
3
4
5
1. Planum sphenoidale
2. Sella
3. Clivus
4. Nasopharynx
5. Sphenoid sinus
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STOPS AROUND THE CSB5#1 - Planum
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CASE 1 Progressively worsening visual acuity
T2 T1+
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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
RSNA 2013: ESSENTIALS OF NEURO IMAGING
CASE 1 Your Diagnosis?
A. Macroadenoma
B. Meningioma
C. Metastatic disease
D. Optic nerve glioma
E. Normal variant
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Skull Base Mengioma
Olfactory Groove Planum Sphenoidale Tuberculum Sella Petroclival
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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
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Curious Features of Meningiomas
Vessel Narrowing Bony Reaction Pneumosinus
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STOPS AROUND THE CSB5#2 - Sella
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CASE 2 Headache, AMS, Visual Deficits
T1 T1+
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CASE 2 Headache, AMS, Visual Deficits
T2 T2*RSNA 2013: ESSENTIALS OF NEURO IMAGING
CASE 2 Your Diagnosis?
A. Hemorrhagic adenoma
B. Rathke cleft cyst
C. Craniopharyngioma
D. Meningioma
E. Chordoma
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CASE 2 Your Diagnosis?
A. Hemorrhagic adenoma
B. Rathke cleft cyst
C. Craniopharyngioma
D. Meningioma
E. Chordoma
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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+
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Diagnostic Key: Where is the Gland?
T1+ T2
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Pituitary Apoplexy
• Acute visual deficit• Intratumoral hemorrhage• Blooming on T2*• Hematocrit levels• Hyperdensity on CT
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FamineDeath War
The Four Horsemen of the APOCALYPSE
ConquestRSNA 2013: ESSENTIALS OF NEURO IMAGING
MeningiomaRathkeAdenoma Craniopharyngioma
The Four Horsemen of the SELLA
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Craniopharyngioma
T1+T2T1
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CT Helps to Confirm Calcification
T2T1
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Craniopharyngioma
• Mostly suprasellar• May enlarge sella• Mixed solid & cystic• Rule of 9’s:
90% calcify (“eggshell”)90% cystic90% enhance90% suprasellar
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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
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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
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STOPS AROUND THE CSB5#3 - Clivus
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CASE 3
T1 T2
Diplopia, CN6 Palsy
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CASE 3
T1+
Diplopia, CN6 Palsy
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CASE 3A. Metastasis
B. Lymphoma
C. Pituitary adenoma
D. Benign osseous lesion
E. Chordoma
Your Diagnosis ?
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CASE 3A. Metastasis
B. Lymphoma
C. Pituitary adenoma
D. Benign osseous lesion
E. Chordoma
Your Diagnosis ?
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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
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• Benign tumor of notochord remants• 2% of autopsies• Asymptomatic• Does not enhance• Clival “pedicle” sometimes present• Recommendation: follow
Ecchordosis Physaliphora
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Chondrosarcoma
• Usually off midline (petro-clival synchondrosis)• Tend to be lower grade tumors• Better prognosis than chordoma• High T2 signal = cartilage
T1
T2 T1+
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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
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Distinguishing Imaging Features ?
Chordoma “Thumb”
Sequestrations Chordoma
Chondroid matrixChondrosarcoma
Osseous Matrix
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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”
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“Arrested” Pneumatization
• Developmental lesion• Nonexpansile• Sclerotic margins• Curvilinear calcification• Intralesional fat
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Diabetic with Cranial Neuropathy x Weeks
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Skull Base Osteomyelitis
T2 T1
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Skull Base Osteomyelitis
T2 T1+
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• Diabetic or immunocompromised
• Headache & cranial neuropathy
• Isolated or contiguous spreadOtitis media & mastoiditisPetrous apicitis
• Key to diagnosis: surrounding inflammatory changes
• Pseudomonas most common
Skull Base Osteomyelitis
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Clival Tumor Mimic
T2 T1 T1+
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Fibrous Dysplasia
• Tumor mimic on MRI!• Expansile but shape preserving• Low T2 signal• Variable enhancement• Key to diagnosis is CT
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STOPS AROUND THE CSB5
#4 - NasopharynxRSNA 2013: ESSENTIALS OF NEURO IMAGING
CASE 4
T1 T1+
Nasal Congestion, Epistaxis
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CASE 4
T2 T1+
Nasal Congestion, Epistaxis
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CASE 4A. JNA
B. Lymphoma
C. Pituitary adenoma
D. Chordoma
E. Meningioma
Your Diagnosis?
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CASE 4 Your Diagnosis?
A. JNA
B. Lymphoma
C. Pituitary adenoma
D. Chordoma
E. Meningioma
RSNA 2013: ESSENTIALS OF NEURO IMAGING
Juvenile Nasopharyngeal Angiofibroma
• Benign but aggressive• Adolescent males• Center within posterior nasal cavity• Expansion of the pterygopalatine fossa• Highly vascular - flow voids• Bone destruction
RSNA 2013: ESSENTIALS OF NEURO IMAGING
Other NP Lesions Involving the CSB
• Nasophayngeal ca• Sinonasal lymphoma• Rhabdomyosarcoma• Infection
RSNA 2013: ESSENTIALS OF NEURO IMAGING
• Nasophayngeal ca• Sinonasal lymphoma• Rhabdomyosarcoma• Infection
Other NP Lesions Involving the CSB
RSNA 2013: ESSENTIALS OF NEURO IMAGING
STOPS AROUND THE CSB5#5 - Sphenoid sinus
RSNA 2013: ESSENTIALS OF NEURO IMAGING
CASE 5
T1+
Headaches & Hypopituitarism
T2 T2
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CASE 5 Headaches & Hypopituitarism
T1 T1+RSNA 2013: ESSENTIALS OF NEURO IMAGING
CASE 5 Headaches & Hypopituitarism
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CASE 5 Your Diagnosis?
A. Chordoma
B. Sphenoid mucocele
C. Fungal infection
D. ICA pseudoaneurysm
E. Macroadenoma
RSNA 2013: ESSENTIALS OF NEURO IMAGING
CASE 5 Your Diagnosis?
A. Chordoma
B. Sphenoid mucocele
C. Fungal infection
D. ICA pseudoaneurysm
E. Macroadenoma
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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!
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Multiple Cranial Neuropathies
T2 T1+ T1
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Sphenoid Mucocele
T2 T1+
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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!