Sellar, suprasellar, and parasellar masses: Imaging features and neurosurgical approaches

Abstract

The sellar, suprasellar, and parasellar space contain a vast array of pathologies, including neoplastic, congenital, vascular, inflammatory, and infectious etiologies. Symptoms, if present, include a combination of headache, eye pain, ophthalmoplegia, visual field deficits, cranial neuropathy, and endocrine manifestations. A special focus is paid to key features on CT and MRI that can help in differentiating different pathologies. While most lesions ultimately require histopathologic evaluation, expert knowledge of skull base anatomy in combination with awareness of key imaging features can be useful in limiting the differential diagnosis and guiding management. Surgical techniques, including endoscopic endonasal and transcranial neurosurgical approaches are described in detail.

Decision-Making in Clival Mass Lesions: Risk Factors for Malignant Disease and an Illustrative Case Example

“…Although histopathological analysis is required for definitive diagnosis, imaging features of clival lesions provide crucial insight in refining the differential and formulating a plan. 10 CT imaging defines bony anatomy, which in turn highlights whether the tumor behavior has been lytic, blastic, erosive, invasive, or simply expansile, among other less common but important changes. 2 MRI is more sensitive than CT for evaluating bone marrow signal abnormalities in the skull base and adjacent soft tissues, as well as the presence and extent of any intracerebral involvement.…”

“…Pituitary adenomas are the most common sellar lesions, and typically present with characteristically weak but homogeneous contrast enhancement and isodense/isointense signal, relative to gland. 3,10 On T2-weighted imaging, they typically appear isointense or hyperintense. 2 Pituitary adenomas smoothly expand the bony sella and lack calcification, which are key distinguishing features from a sellar meningioma.…”

“…10,11 Macroadenomas (>10 mm) are more prevalent than microadenomas, and invade into the cavernous sinus in up to 10% of cases, which increases the risk of surgical morbidity. 10 Secreting pituitary tumors represent a minority of microadenomas, and present with distinct clinical and laboratory features that are often diagnostic. 12 Meningiomas are the most common benign primary central nervous system neoplasm, and frequently demonstrate iso-to hyperdense CT and iso-to hypointense T1-and T2-weighted MRI findings.…”

“…12 Meningiomas are the most common benign primary central nervous system neoplasm, and frequently demonstrate iso-to hyperdense CT and iso-to hypointense T1-and T2-weighted MRI findings. 10 Characteristic features of meningiomas include the presence of a wide dural base with an enhancing dural tail, hyperostosis of adjacent bone, and unambiguous differentiation from pituitary gland tissue. 10 Rathke's cleft cysts (RCC) and craniopharyngiomas are congenital and neoplastic lesions arising from remnants of the Rathke pouch, respectively.…”

“…10 Characteristic features of meningiomas include the presence of a wide dural base with an enhancing dural tail, hyperostosis of adjacent bone, and unambiguous differentiation from pituitary gland tissue. 10 Rathke's cleft cysts (RCC) and craniopharyngiomas are congenital and neoplastic lesions arising from remnants of the Rathke pouch, respectively. Both of these entities have the potential to appear as suprasellar lesions, but differ in their complexity, 3,13 with RCCs appearing as simple, typically nonenhancing cysts, in comparison to the polycystic, heterogeneous, often partially intraventricular appearance of craniopharyngiomas.…”