Parasellar tumors: suprasellar and cavernous sinuses

Neoplasms and tumor-like lesions of the sellar region: imaging findings with correlation to pathology and 2021 WHO classification

The sellar region represents a complex anatomical area, composed of multiple structures of different embryological derivation, including the skull base and the pituitary gland, along with vascular, nervous, and meningeal structures. Masses arising in this region include benign and malignant lesions arising from the pituitary gland itself, but also from vestigial embryological residues or surrounding tissues, that may require different therapeutic approaches. While assessing sellar region masses, the combination of clinical presentation and imaging features is fundamental to define hypotheses about their nature. MR represents the imaging modality of choice, providing information about the site of the lesion, its imaging features, and relation with adjacent structures, while CT is useful to confirm the presence of lesion calcifications or to reveal tumor invasion of bony structures. The aim of this pictorial review is to provide an overview of the common neoplasms and tumor-like conditions of the sellar region, according to the 2021 WHO Classification of Tumors of the Central Nervous System (fifth edition), with an emphasis on the radiologic-pathologic correlation. After a brief introduction on the anatomy of this region and the imaging and pathological techniques currently used, the most relevant MRI characteristics, clinical findings, and pathological data, including histologic and molecular features, will be shown and discussed, with the aim of facilitating an appropriate differential diagnosis among these entities.

Sellar and parasellar lesions: multidisciplinary management

Introduction

The endoscopic endonasal transsphenoidal approach to the sella and parasellar regions is now increasingly used for removal of a variety of lesions localized in the ventral skull base. The advantage of the endoscope is enhanced visualization and improved panoramic view that can result in more complete removal of the tumor. An extensive knowledge of the anatomy is mandatory to approach this region.

Materials and methods

From February 2009 to March 2020, the endoscopic endonasal approach was used in 153 patients with sellar and parasellar lesions, at our Institution: 136 pituitary adenomas, 7 craniopharyngiomas, 3 Rathke’s cysts, a tuberculum sellae meningioma, an aneurysm of the internal carotid artery (ICA), a clivus chordoma, a papillary glioneuronal tumor, an histiocytosis, a pituitary metastasis from breast cancer and a chondrosarcoma.

Results

The most common surgical complications were cerebral spinal fluid leak (9), bleeding (2), pituitary abscess (2). Among endocrinological complications, the most important were diabete insipidus (23) and panhypopituitarism (3). Two patients complicated with meningitis. There were no visual worsening and no operative mortality. We had persistence of disease in 20 cases. Twelve patients underwent surgical revision for recurrence of the disease.

Conclusions

Pre-operative planning and collaboration with several specialists are necessary in order to offer the patient the best treatment, minimizing complications.

Diabetes insipidus secondary to sellar/parasellar lesions

Diabetes insipidus (DI) is a well-recognised transient or permanent complication following transsphenoidal surgery for pituitary adenomas or other sellar/parasellar lesions. However, data regarding the prevalence of pre-operative DI in sellar/parasellar lesions other than pituitary adenomas are scarce. We systematically reviewed the existing data for defining the prevalence of DI before any treatment in adult patients with sellar/parasellar lesions, excluding pituitary adenomas and metastatic lesions. In total, 646 patients with sellar/parasellar lesions presenting with DI at diagnosis were identified. The most common pathologies of sellar/parasellar lesions presenting with DI at diagnosis were lymphocytic hypophysitis (26.5%), craniopharyngiomas (23.4%), Langerhans's cell histiocytosis (18.9%) and Rathke's cleft cyst (12.7%), accounting for the vast majority (more than 80%) of these lesions. Overall, DI at diagnosis was found in 23.4% of all patients with sellar/parasellar lesions, albeit with a wide range from 10.6% to 76.7%, depending on the nature of the pathology. The highest prevalence of DI was found in less commonly encountered lesions namely germ-cell tumours (76.7%), abscesses (55.4%) and neurosarcoidosis (54.5%), each accounting for less than 3% of all sellar/parasellar lesions. Most DI cases (68.8%) were associated with anterior pituitary hormonal deficiencies, in contrast to pituitary adenomas that rarely present with DI. The enlargement and enhancement of the pituitary stalk were the most common findings on magnetic resonance imaging besides the loss of the high signal of the posterior pituitary on T1-weighted images. Resolution of DI spontaneously or following systemic and surgical management occurred in 22.4% of cases. Post-operative DI, not evident before surgery, was found in 27.8% of non-adenomatous sellar/parasellar lesions, and was transient in 11.6% of them. Besides distinctive imaging features and symptoms, early recognition of DI in such lesions is important because it directs the diagnosis towards a non-adenomatous sellar/parasellar tumour and the early initiation of appropriate treatment.

Phantosmia as the first presentation of a cavernous sinus - clinoidal meningioma

Cavernous sinus meningiomas (CSM) are complex skull base lesions that, due to their particular anatomical location, render surgical management difficult. Their symptomatology is versatile, and the clinical outcome is difficult to predict. We present the case of a 57-year old female patient who experienced phantosmia - an abnormal, persistent, olfactory sensation of cigarette smell for 18 months. MRI was performed and revealed a left cavernous sinus meningioma, extending into the left temporal fossa, with olfactory and optic nerve distortion. To our knowledge, this is the first reported case of phantosmia as the initial presentation of a lesion in the cavernous sinus.

Parasellar meningioma presenting by stroke and bilateral occlusion of the internal carotid arteries: A case report

Cerebrovascular stroke caused by skull base meningioma has been rarely reported. A 30-year-old male presented (April 2015) with acute right-sided hemiplegia. His brain neuroimaging (computerized tomography and magnetic resonance imaging) showed left ischemic infarction in the territory of middle cerebral artery. Magnetic resonance imaging also showed a right parasellar solid lesion which extended to the right basisphenoid and cavernous sinus and attenuated the right internal carotid artery. It also had left smaller parasellar extension. The lesion enhanced uniformly and strongly following gadolinium injection. Digital subtraction angiography using selective catheterization of both common carotid and left vertebral arteries (07/13/2015) showed occlusion of both internal carotid arteries and faint visualization of left terminal internal carotid artery and its bifurcation. The right internal carotid artery and its branches were not visualized. Left vertebral injection showed prominent left vertebral and basilar arteries and filling of both internal carotid arteries through posterior communicating arteries. A faint blush of contrast was noticed at the parasellar region coinciding with meningioma. The patient received three treatment sessions of gamma knife radiosurgery as follow: 20 cc of the tumor was treated with 12 Gy (15 August 2015), 1.7 cc was treated with 10 Gy (31 January 2016), and 2.5 cc was treated with 11 Gy (13 August 2016) which resulted in complete clinical recovery and tumor size reduction. Compensation from the posterior communicating and external carotid arteries might explain the complete clinical recovery after tumor size reduction with gamma knife radiosurgery.

Radiotherapy of Parasellar Tumours

Parasellar tumours represent a wide group of intracranial lesions, both benign and malignant. They may arise from several structures located within the parasellar area or they may infiltrate or metastasize this region. The treatment of the tumours located in these areas is challenging because of their complex anatomical location and their heterogenous histology. It often requires a multimodal approach, including surgery, radiation therapy (RT), and medical therapy. Due to the proximity of critical structures and the risks of side effects related to the procedure, a successful surgical resection is often not achievable. Thus, RT plays a crucial role in the treatment of several parasellar tumours. Conventional fractionated RT and modern radiation techniques, like stereotactic radiosurgery and proton beam RT, have become a standard management option, in particular for cases with residual or recurrent tumours after surgery and for those cases where surgery is contraindicated. This review examines the role of RT in parasellar tumours analysing several techniques, outcomes and side effects.

Nonneuroendocrine Neoplasms of the Pituitary Region

CONTEXT

Although most sellar lesions are related to pituitary adenomas, the region gives rise to a variety of neoplasms that can be associated with substantial morbidity and/or mortality.

DESIGN

Information from reviews and guidelines of relevant societies dealing with such neoplasms, as well as articles that have provided new developments that made important contributions to their pathogenesis and treatment up to 2018, were obtained: public indexes such as PubMed/MEDLINE were used with the relevant search items.

RESULTS

Sellar neoplasms have a worse outcome than pituitary adenomas that is related not only to their natural history but also to side effects of therapies and evolving endocrine and/or hypothalamic deficiencies. Recent imaging advances have established the radiological fingerprint of some of these neoplasms, and several chromosomal aberrations have also been identified. Although established approaches along with new surgical and radiotherapeutic approaches remain the main treatment modalities, recent evidence has provided insight into their molecular pathogenesis involving, other than chemotherapy, treatments with targeted agents as in gliomas and craniopharyngiomas bearing BRAF mutations. Development of predictive markers of recurrences may also identify high-risk patients, including proliferative markers and expression of the progesterone receptor in meningiomas, and lead to less aggressive surgery. Owing to the rarity and complexity of these neoplasms, patients should be managed in dedicated centers.

CONCLUSIONS

The diagnosis and management of sellar neoplasms necessitate a multidisciplinary approach. Following evolving recent advances in their diagnosis and therapy, such a multidisciplinary approach needs to be extended to establish evidence-based diagnostic and management plans.

Suprasellar keratinous cyst: A case report and review on its radiological features and treatment outcome

BACKGROUND

Keratinous or epidermoid cysts (ECs) are encapsulated lesions lined by squamous cell epithelium. They comprise approximately 1% of intracranial lesions. Contrary to dermoid cysts, they lack dermal elements such as sebaceous or apocrine glands and hair follicles. The sellar region is the second most common intracranial site following the cerebellopontine angle. Here, we report a case of EC in a patient who complained of endocrine disturbances. We also performed a systematic review on previously published cases to analyze clinical and radiological characteristics and report the treatment outcomes of suprasellar ECs.

CASE DESCRIPTION

A 42-year-old woman presented with a one-year history of amenorrhea, weight gain, severe headache, and visual disturbances for 6 months. Work-up identified an elevated prolactin level and a temporal field defect of the right eye. Magnetic resonance imaging (MRI) showed a cystic suprasellar lesion pushing on the optic chiasm. She underwent endoscopic trans-sphenoidal surgery, which confirmed a keratinous cyst on histology. Postoperatively, complete resection was confirmed on imaging. She did well although her hospital stay was prolonged due to diabetes insipidus and hypocortisolism.

CONCLUSION

Chronic endocrine disturbances can be the presenting complaints of a suprasellar EC, whose T1-weighted MRI appearance can be non-specific, mimicking other differential diagnoses, such as a Rathke's cleft cyst. However, the T2-weighted MRI appearances of ECs are generally hyper-intense and lesions show diffusion restriction. Treatment is surgical and yields good outcomes in most cases reported.

A morphometric and analytical cadaver dissection study of a tumor-simulation balloon model

We quantified the effects on anatomical cadaver dissection of a balloon-inflation tumor model positioned in the parasellar region and approached through an orbitozygomatic (OZ) craniotomy. A modified supraorbital OZ was performed bilaterally on 5 silicon-injected cadaver heads. Ten predetermined anatomical points assigned using a frameless stereotactic device were used to measure the working area of exposure, degree of surgical freedom, and horizontal and vertical angles of attack to specific target points before and after inflation of a balloon catheter mimicking a parasellar tumor. Balloon inflation displaced the central anatomical structures (pituitary stalk, lamina terminalis, anterior chiasm, and internal carotid artery [ICA]-posterior communicating artery and ICA-A1 junctions) by 14-51% (p ≤ .05). With tumor simulation, the vertical angle of attack increased by 67% (p < .01), while the area of exposure increased by 83% (p < .01) and surgical freedom increased by 58% (p < .01). This tumor model also significantly displaced central anatomical sella-associated structures. Compared to a normal anatomical configuration, the tumor simulation (balloon) opened surgical corridors (especially vertical) and acted as a natural retractor, widening the angle of access to the infundibular apex-hypothalamic junction. Although this model cannot exactly mimic a tumor mass in a patient, the effects of tumor compression and sequential displacement of important structures can be combined into and then assessed in a cadaveric neurosurgical anatomical scenario for training and research.

MANAGEMENT OF ENDOCRINE DISEASE: Pituitary 'incidentaloma': neuroradiological assessment and differential diagnosis

Pituitary incidentalomas are a by-product of modern imaging technology. The term 'incidentaloma' is neither a distinct diagnosis nor a pathological entity. Rather, it is a collective designation for different entities that are discovered fortuitously, requiring a working diagnosis based on the input of the radiologist, endocrinologist and often a neurosurgeon. In addition to pathological conditions affecting the pituitary gland, a thorough knowledge of the radiological characteristics of normal variants and technical artifacts is required to arrive at an accurate differential diagnosis. After careful radiological and hormonal evaluation, the vast majority of pituitary incidentalomas turn out to be non-functioning pituitary microadenomas and Rathke's cleft cysts (RCCs). Based on the low growth potential of non-functioning pituitary microadenomas and RCCs, periodic MRI surveillance is currently considered the optimal management strategy. Stricter follow-up is required for macroadenomas, as increases in size occur more frequently.

Imaging in Endoscopic Cranial Skull Base and Pituitary Surgery

Endoscopic endonasal approaches have widely accepted techniques for managing benign and malignant processes along the entire ventral skull base with similar or better results compared with open procedures, but with lower rates of complication. Managing pathology affecting the skull base can be challenging because of complex anatomy and the proximity of critical neurovascular structures. Postoperative imaging can be challenging, because of surgical alterations of normal anatomy and the now common use of complex reconstruction techniques. Understanding the normal imaging appearance of skull base reconstruction is important for accurate postoperative interpretation and delineation between normal reconstructive tissue and recurrent neoplasm.

Pituitary incidentalomas: A guide to assessment, treatment and follow-up

Pituitary incidentalomas are lesions which are detected incidentally in the pituitary gland during imaging procedures for unrelated causes, such as headache, trauma or symptoms involving the neck or central nervous system. The wide application of sensitive brain imaging techniques (CT, MRI) has led to an increasing recognition of such lesions. Although the etiology of pituitary incidentalomas covers a wide range of pathologies, most of them (∼90%) are benign adenomas; nonetheless, they may result in visual and/or neurologic abnormalities. By definition, micro-incidentalomas have maximum diameter of less than 1cm, while macro-incidentalomas are at least 1cm. Micro-incidentalomas have a reported mean prevalence in normal individuals of around 10%. The endocrinologist facing a pituitary incidentaloma has to solve two main diagnostic problems: (i) the nature and extent of the lesion, and (ii) whether hormonal excess or deficits result from the lesion. The former is achieved by the use of pituitary MRI and visual field (VF) examination and the latter by basal or dynamic hormonal assessments. The answers to these two questions will guide the treatment and follow-up. VF deficits or neurological disturbances due to compression of the optic chiasm or nerve by the incidentaloma are the strongest recommendations for surgery. Furthermore, hormonally active incidentalomas, with the exception of prolactinomas, should be treated by surgery. Most cases of pituitary incidentalomas do not meet criteria for surgical excision, but may require follow-up. The follow-up strategy consists of clinical evaluation, pituitary MRI, VF examination and hormonal assessments. Macro-incidentalomas require more extensive initial investigation, as well as closer MRI surveillance, than micro-incidentalomas. Diagnostic, treatment and follow-up strategies should be in alignment with the optimal personalized clinical benefit.

Diabetes Insipidus: An Unusual Presentation of Adenocarcinoma of the Lung in a Patient with no Identifiable Lung Mass

Context:

Lung cancers are known to metastasize to unusual sites. Despite this knowledge often times the diagnosis of a primary lung cancer gets delayed especially when the patient presents without respiratory symptoms.

Case Report:

The patient discussed in our review is a 47-year-old female, smoker who had presented to several hospitals with months of headache, nausea and intermittent episodes of vomiting. She was noted to have hypernatremia due to diabetes insipidus and a pituitary lesion on her magnetic resonance images. The pituitary mass on biopsy was found to represent a metastatic focus from a primary lung adenocarcinoma.

Conclusion:

Clinicians should be aware of malignancies that are well known to metastasize to the posterior pituitary. Conversely, since not every patient presents with symptoms of metastasis, there is a need to recognize the clinical syndromes (e. g., diabetes insipidus-like symptoms or more subtle symptoms like cranial nerve palsies) associated with potential metastasis to the pituitary.

Magnetic resonance imaging of sellar and juxtasellar abnormalities in the paediatric population: an imaging review

The sellar and juxtasellar regions in the paediatric population are complex both anatomically and pathologically, with magnetic resonance imaging (MRI) being the "gold standard" imaging modality due to the high contrast of detail. Assessment requires a detailed understanding of the anatomy, embryology, pathophysiology and normal signal characteristics of the pituitary gland and surrounding structures in order to appropriately characterise abnormalities. This article aims to provide an overview of the imaging characteristics of developmental/congenital and acquired disease processes which affect the sellar and juxtasellar region in the paediatric population. Main Messages • The sellar region is anatomically complex and covers a wide pathology spectrum. • MRI is the key imaging modality to assess sellar and juxtasellar pathology. • Numerous developmental anomalies may not be discovered until adulthood. • Knowledge of pathology alerts and guides the clinician towards appropriate management.

Pretreatment diagnosis of suprasellar papillary craniopharyngioma and germ cell tumors of adult patients

BACKGROUND AND PURPOSE

Suprasellar papillary craniopharyngiomas and germ cell tumors in adults share some clinical and imaging similarities but have different therapeutic strategies and outcomes. This study aimed to evaluate the pretreatment diagnosis of these 2 tumors to improve the therapeutic outcome.

MATERIALS AND METHODS

We retrospectively enrolled 18 adults with papillary craniopharyngiomas and 17 with germ cell tumors. The MR imaging findings were evaluated, including signal change and anatomic extension. The medical records were reviewed to collect clinical findings, management, and outcomes.

RESULTS

The clinical findings of papillary craniopharyngiomas versus germ cell tumors were as follows: age: 46 ± 13.9 years versus 23 ± 7.1 years (P < .0001); diabetes insipidus: 2/18 (11%) versus 11/17 (65%) (P = .001); recurrence 13/16 (81%) versus 4/17 (24%) (P = .0031). The MR imaging findings of papillary craniopharyngiomas versus germ cell tumors were as follows—pituitary stalk thickening: 1.6 ± 0.4 mm versus 5.4 ± 4.2 mm (P < .0001); vertical infundibular extension: 1/18 (6%) versus 16/17 (94%) (P < .0001); sagittal spheric shape: 17/18 (94%) versus 1/17 (6%) (P < .0001); diffusion restriction: 1/17 (6%) versus 8/12 (67%) (P = .0009).

CONCLUSIONS

Younger age, diabetes insipidus, MR imaging characteristics of restricted diffusion, and vertical infundibular extension favor the diagnosis of germ cell tumors. Spheric shape without infundibular infiltration provides clues to papillary craniopharyngiomas, which originate from the pars tuberalis and are located outside the third ventricle. We suggest that suprasellar germ cell tumor is possibly an intraventricular lesion. Appropriate treatment planning can be initiated according to the diagnosis and anatomic location.

Tumors invading the cavernous sinus that cause internal carotid artery compression are rarely pituitary adenomas

There is a clinical impression that when tumors invade the cavernous sinus, compression of the internal carotid artery is rare with pituitary adenomas and more common with other types of lesions but there are no actual data to support this impression. To confirm the impression that the finding of internal carotid artery compression by tumors invading the cavernous sinus is inconsistent with a diagnosis of a pituitary adenoma, we performed a retrospective analysis of MRI scans performed between 2000 and July 2009. An initial search of the radiology database was performed using the terms "invasive mass cavernous MRI" and subsequent refinement narrowed the evaluation to 141 patients with cavernous sinus invasion by sellar/parasellar tumors for whom there were clinical/pathological data to determine tumor type. 83 of the 141 patients with cavernous sinus invasion had carotid artery encasement; 58 were pituitary adenomas and 25 were other types of lesions. Eight of these 83 scans revealed compression of the internal carotid lumen, with only one being a pituitary adenoma and seven being other types of lesions. Therefore, only 1/58 (1.7%) of pituitary adenomas and 7/25 (28%) of non-pituitary adenoma lesions that encased the internal carotid artery caused compression of the artery (P = 0.0007). A mass lesion that invades the cavernous sinus and encases the internal carotid artery is very unlikely, therefore, to be a pituitary adenoma if it compresses the lumen of the internal carotid artery.

Rare Tumors of the Sellar Region

Context

The sellar/ parasellar region is the location for a vast array of neoplastic and nonneoplastic intracranial space-occupying lesions. While several common lesions arising in this location have been well-described in the literature, there are rare and challenging tumors that may also arise in this region.

Objective

We focus this review on five rare tumors reported to arise in the sellar region, including spindle cell oncocytoma of the adenohypophysis, pituicytoma, intravascular papillary endothelial hyperplasia, epithelioid hemangioendothelioma and xanthogranuloma. We review their clinical presentation, histologic features, differential diagnosis and outcomes for these tumors.

Data sources

All medical literature pertaining to these entities that was searchable on PubMed was comprehensively reviewed.

Conclusions

Spindle cell oncocytoma and pituicytoma have recently been included in the 2007 edition of the World Health Organization classification of tumours of the CNS, while intravascular papillary endothelial hyperplasia, epithelioid hemangioendothelioma and xanthogranuloma have only rarely been described in this region. Knowledge of these may help prevent possible diagnostic pitfalls during postmortem evaluation.

Follicular thyroid carcinoma with metastases to the pituitary causing pituitary insufficiency

BACKGROUND

Pituitary metastases are found in about 1% of all pituitary resections. They often derive from breast, lung, and gastroenteric tract adenocarcinomas, very rarely from thyroid carcinoma. Presenting symptoms of thyroid carcinoma metastatic to the pituitary gland are usually chiasmatic with central neurological impairment due to space-occupying expansion in the parasellar region. Hypopituitarism is more often associated with papillary and medullary rather than follicular thyroid carcinoma (FTC). Here we describe a patient with pituitary metastasis from FTC who had hypopituitarism with thyrotropin (TSH) deficiency.

SUMMARY

A 61-year-old woman, who presented with visual deficits and pain to the right orbit, was found on magnetic resonance imaging to have a large mass involving the pituitary gland. She was found to have pituitary insufficiency based on corticotropin-releasing hormone and TSH-releasing hormone testing. Transnasopharyngeal biopsy of the mass revealed metastases from FTC. After total thyroidectomy, which confirmed widely invasive FTC, the patient underwent external beam radiation therapy of the metastases for progressive neurological symptoms and an increase in orbit pain. Since endogenous TSH production was insufficient, we used recombinant human TSH (rhTSH) as preparation for a series of radioiodine treatments. rhTSH administration, followed by 7.4 GBq of (131)I, was repeated seven times over a 10-year period. This was associated with a marked decrease in serum thyroglobulin levels accompanied by substantial clinical improvement, but after 7 years disease progression occurred.

CONCLUSIONS

Seven patients with pituitary metastases from FTC have been reported. In all cases, some neurological signs and symptoms related to mass effect were reported, but no pituitary insufficiency was described. This may be the first case of FTC with metastases to the pituitary causing hypopituitarism. It seems likely that management of such cases could be limited to biopsy to confirm thyroid carcinoma, rather than more extensive surgery, and that this could be followed by multiple treatments with rhTSH followed by (131)I.

Pituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients

CONTEXT

Sellar and parasellar masses present with overlapping clinical and radiological features ranging from asymptomatic incidental presentations and hormonal effects to compressive local mass effects. Pituitary masses are diagnosed with increased frequency with magnetic resonance imaging (MRI) advancements and availability, but indications and diagnostic outcomes of MRI screening for sellar lesions are not defined. Although pituitary adenomas are the most frequently encountered sellar mass lesions, other etiologies should be considered in the differential diagnosis of a sellar mass.

SETTING

The study was conducted at a tertiary pituitary center.

PATIENTS

This study was a retrospective review of 2598 subjects undergoing at least one pituitary MRI scan from 1999 to 2009.

MAIN OUTCOME MEASURE

Prevalence and diagnosis of specific sellar and parasellar masses as screened by pituitary MRI.

RESULTS

The most common indications for pituitary imaging, excluding known mass follow-up, were for evaluation of hyperprolactinemia or hypogonadism. A normal pituitary gland was reported in 47% of subjects undergoing pituitary MRI. The most common pituitary adenomas initially identified by MRI included prolactinoma (40%), nonfunctioning adenoma (37%), and GH adenoma (13%). Nonadenomatous sellar masses accounted for 18% of visible lesions, of which the most common were Rathke's cleft cyst (19%), craniopharyngioma (15%), and meningioma (15%). Metastases accounted for 5% of nonpituitary lesions and breast cancer was the most common primary source.

CONCLUSIONS

Half of all pituitary MRI scans performed in a large patient population yielded no visible lesion. Nonadenomatous pituitary lesions should be considered in the diagnosis of sellar masses observed on MRI, and a high clinical suspicion is required to exclude the presence of a nonfunctioning pituitary adenoma.

Dynamic enhancement features of cavernous sinus cavernous hemangiomas on conventional contrast-enhanced MR imaging

BACKGROUND AND PURPOSE

The reported MR imaging characteristics of cavernous sinus cavernous hemangiomas (CSCHs) in the literature are nonspecific. The purpose of our study was to explore dynamic enhancement features of CSCHs on conventional contrast-enhanced MR imaging and to correlate these features with histopathologic subtypes.

MATERIALS AND METHODS

Twenty-one patients (8 male and 13 female; age range, 13-63 years; average age, 42.6 years) with surgically confirmed CSCHs were retrospectively investigated. Preoperative MR study was performed in all cases, consisting of T1-weighted axial imaging, T2-weighted axial imaging, T1-weighted sagittal imaging, and contrast-enhanced T1-weighted axial, sagittal, and coronal images.

RESULTS

There were 4.8% (1/21) that showed homogeneous enhancement on all 3 contrast-enhanced sequences, whereas 95.2% (20/21) demonstrated heterogeneous enhancement on the first contrast-enhanced sequence. Among the 20 lesions, on subsequent contrast-enhanced sequences, 55.0% (11/20) showed homogeneous enhancement, whereas 35.0% (7/20) of lesions showed progressive contrast "filling in." The remaining 10% (2/20) exhibited no apparent enhancement changes. The 95.2% (20/21) of lesions with heterogeneous enhancement on the first contrast-enhanced sequence correlated with type B or type C pathologic findings, whereas 4.8% (1/21) with homogeneous enhancement correlated with type A pathologic findings. Among the 20 type B or type C lesions, 80% (16/20) achieved total or near-total resection.

CONCLUSION

Progressive contrast "filling in" in the tumors on conventional contrast-enhanced MR images can aid in differentiating between cavernous sinus lesions and suggest the diagnosis of cavernous hemangiomas.