Case Report:

Case Report,
Ganapathy,
Legasto
Wong,
and Naffaa
Waite

Cystic Suprasellar Mass

S. Srinivas Ganapathy, M.D., Paul Wong, M.D., Lena Naffaa, M.D.

Department of Radiology, Akron Children’s Hospital, Akron, OH

Case Presentation
A 12-year-old child presented with headaches for 3 months, gradual onset of blurred vision, and strabismus
in the right eye. The patient had bitemporal hemianopia and severe vision loss in the right eye on exam. Central
hypothyroidism (low free T4 and normal TSH) and adrenal insufficiency (low serum cortisol and low sodium)
were the endocrine abnormalities present. This prompted further evaluation by computed tomography (CT)
and, subsequently, MRI with contrast (Figure 1 A-D).

A B

C D

FIGURE 1. Sagittal reformatted CT image without contrast (A) depicts a suprasellar and intrasellar mass with peripheral calcifi-
cations. Coronal T2-weighted image (B) shows diffuse hyperintensity, consistent with the cystic nature of the mass. Sagittal (C)
and fat-saturated coronal (D) postcontrast T1 images reveal rim enhancement of the mass with small solid nodular enhancing
foci along the inferior and dorsal aspect of the mass.

J Am Osteopath Coll Radiol 2016; Vol. 5, Issue 1 Page 23

 Case Report: Ganapathy, Wong, Naffaa
Key Imaging Finding
Cystic suprasellar mass in a child
Differential Diagnoses
Craniopharyngioma
Rathke’s cleft cyst
Pituitary macroadenoma (necrotic)
Chiasmatic/hypothalamic glioma
Suprasellar arachnoid cyst
Discussion
Suprasellar masses have a wide
differential diagnosis that can be nar-
rowed based on patient age; clinical
presentation; imaging characteristics
including the presence of calcifications,
cystic content of the mass, and patterns
of enhancement; sellar extension; and
appearance of the infundibulum. The
differential diagnosis of a cystic su-
prasellar mass in a child includes more
common etiologies such as craniophar-
yngioma and Rathke’s cleft cyst, as
well as less common entities such as a
necrotic pituitary adenoma, cystic gli-
oma, and suprasellar arachnoid cyst.
Craniopharyngioma. Craniophar-
yngiomas are benign epithelial tumors
known to arise from the squamous rests
along the remnants of the hypophyse-
al-Rathke (craniopharyngeal) duct. They
are most commonly suprasellar in loca-
tion but can also be mixed intra-suprasel-
lar or, rarely, purely intrasellar. Varying
locations occur because they can arise
anywhere along the pituitary stalk from
the floor of the third ventricle to the pi-
tuitary gland. A small number of cranio-
pharyngiomas can be ectopic, located in
the third ventricle, nasopharynx, or sphe-
noid sinus. Giant craniopharyngiomas
are known to extend into the anterior,
middle, or posterior cranial fossae.
Craniopharyngioma is the most
common nonglial pediatric intracranial
tumor and comprises over half of all
pediatric suprasellar tumors. The peak
incidence is between 10-14 years of
age (adamantinomatous subtype) with
a second peak in the 4th to 6th decade
(squamous-papillary subtype). 1 The
most common symptoms at presenta-
tion are headaches, visual field defects,
or anterior pituitary dysfunction.
Page 24
Craniopharyngiomas vary in size
with the larger tumors being predomi-
nantly cystic and complex with a mul-
tilobulated appearance. Nearly 90% of
the pediatric (adamantinomatous) vari-
ant of craniopharyngiomas have cal-
cifications and cysts, and demonstrate
enhancement of the wall or solid por-
tions, which are distinguishing imag-
ing features.2 The cystic areas can be of
varying signal intensity on T1-weighted
images depending on the protein or
cholesterol content. The solid portion
can also be heterogeneous on T1 and
T2 sequences. CT is more sensitive to
detect calcifications, as is illustrated in
this case. MR spectroscopy evaluation
of craniopharyngiomas shows a broad
lipid spectrum and no normal metabo-
lite peaks.3
The surgical approach to cranio-
pharyngiomas varies depending on the
pre-chiasmatic or retro-chiasmatic loca-
tion of the tumor. The tumor has a good
10-year overall survival rate, although
the rate of recurrence is high and can be
greater than 80% if the original tumor
was greater than 5 cm.4 Recurrence may
occur within the tumor bed or along the
surgical tract.
Rathke’s cleft cyst. Rathke’s cleft
cysts are embryologically related to
craniopharyngiomas, as they are de-
rived from the remnants of Rathke’s
pouch. They are cystic intra or su-
prasellar masses, similar to craniophar-
yngiomas, but do not enhance or have
calcifications. They are smaller when
compared to craniopharyngiomas and
are just anterior to the pituitary stalk in-
sertion, most often in the region of pars
intermedia. Despite the cystic nature
(typically low T1 signal and high T2
signal), Rathke’s cleft cysts can also be
T1 hyperintense and iso- to hypointense
on T2-weighted images due to pro-
teinaceous content. A nonenhancing
intracystic nodule having high signal in-
tensity on T1-weighted images and low
signal intensity on T2-weighted images
was observed in 77% of the cases in one
series; if present, it is a helpful feature
to distinguish these lesions.5 Rathke’s
cleft cysts are mostly asymptomatic in
J Am Osteopath Coll Radiol 2016; Vol. 5, Issue 1
childhood. However, they can occa-
sionally present with pituitary dysfunc-
tion, visual disturbances, or headaches
due to compression of the pituitary
gland or suprasellar structures.
Pituitary macroadenoma (ne-
crotic). Pituitary macroadenomas in
children are more common than mi-
croadenomas. However, an adolescent
pituitary gland can be enlarged normally
due to hormonal influences with an up-
ward convexity resembling an adenoma,
but without differential enhancement
or extension. Pituitary macroadenomas
can expand the sella and extend into the
suprasellar region. They may also show
hemorrhagic or proteinaceous cystic
changes with T1 hyperintensity, mim-
icking craniopharyngiomas, but they
rarely calcify. The solid portions typi-
cally enhance uniformly, whereas the
necrotic, cystic, or hemorrhagic portions
do not. Macroadenomas can expand lat-
erally and invade the cavernous sinus.
When hemorrhage or apoplexy occurs
in suprasellar adenomas, susceptibil-
ity-weighted sequences are helpful to
identify blood products, which can be
markedly hypointense on T2-weighted
images.6 Pituitary apoplexy is an emer-
gency that can result in permanent visual
loss if not immediately addressed.
Chiasmatic/hypothalamic glioma.
Chiasmatic/hypothalamic gliomas or
astrocytomas are markedly T2 hyperin-
tense and hypointense on T1-weighted
images. The large, bulky chiasmatic
gliomas are often heterogeneous with
cystic and enhancing solid components.
They may infiltrate or extend along the
optic chiasm and into the optic nerves,
tracts, or radiations, rather than dis-
placing them as is the case with cranio-
pharyngiomas—a key distinguishing
imaging feature. Lesions may occur
sporadically or in the setting of neu-
rofibromatosis type 1 (NF1) in which
case there is an increased incidence.7
Occurrence before age 5 in a patient
with cutaneous stigmata of NF1 favors
a diagnosis of astrocytoma over cranio-
pharyngioma in this location.
Arachnoid cyst. Suprasellar arach-
noid cysts are congenital lesions that

can expand by cerebral spinal fluid
secretion. The cyst wall may be im-
perceptible on CT and even on MRI.
Arachnoid cysts do not show contrast
enhancement, solid components or
calcifications.8 Suprasellar arachnoid
cysts, like craniopharyngiomas, can ex-
pand in all directions and can displace
the third ventricle. They may disrupt the
pituitary stalk and compress the hypo-
thalamus. Arachnoid cysts can typically
be distinguished from other entities in
this location by their isointensity to CSF
on all sequences.
Additional considerations. Other
entities to consider in the differential
of a cystic suprasellar mass include
dermoids/epidermoids and teratomas,
although they are less common midline
lesions. Dermoids and teratomas often
show presence of fat on CT or MR.
Epidermoids are solid lesions that can
mimic cysts, but show characteristic
restricted diffusion. The enhancement
is minimal, if at all present.9 The ecto-
pic craniopharyngioma arising from
the sphenoid sinus can be distinguished
by the presence of calcifications, as op-
posed to a sphenoid sinus mucocele,
J Am Osteopath Coll Radiol 2016; Vol. 5, Issue 1
Case Report:
which typically lacks calcifications.
Sphenoid sinus mucoceles primarily
arise in the sinus completely filling it
and can cause bone destruction. Other
suprasellar masses, such as a meningi-
oma, aneurysm, Langerhan’s cell his-
tiocytosis, germinoma, hamartoma, and
chordoma most often do not have a pre-
dominantly cystic appearance.
Diagnosis
Craniopharyngioma
Summary
A cystic suprasellar mass with calci-
fications and enhancement of the wall
or solid portions in a child or adoles-
cent is almost always a craniopharyn-
gioma. It is important to recognize the
various locations along the hypoph-
yseal-Rathke duct from which these
tumors can arise and extend into mul-
tiple cranial fossae. The presence of
calcifications, a distinguishing feature
of craniopharyngioma, as opposed to
several other entities in this location, is
best depicted by CT, which is a valuable
complement to MRI. When interpreting
postoperative studies, one should be
Case Report,
Ganapathy,
Legasto
Wong,
and Naffaa
Waite
cognizant of the high recurrence rate of
pediatric craniopharyngiomas either in
the tumor bed or ectopically along the
surgical tract.
References
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