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23b - Answer: 61-year-old female presents with memory loss

Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
Includes DICOM files

HISTORY: 

This 61-year-old female presents with memory loss, headaches, and history of concussions. 7th nerve palsy.

(QUIZ ANSWER) POTENTIAL DIFFERENTIAL: 

All of the above.

Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.

FINDINGS:

Diffusion-weighted images are without a diffusion-restrictive defect. No mass within the masticator, parapharyngeal or pharyngeal mucosal spaces. 

No internal auditory canal or cerebellopontine angle masses. 

No extraaxial collections or hemorrhage. No obstructive hydrocephalus. 

Right maxillary sinus mucosal thickening. 

T2 hyperintensity within the sella measuring 9mm which is to the left of midline may represent a pars intermedia cyst. Additional differential could include craniopharyngioma, cystic adenoma. 

Carotid and basilar artery flow voids are intact. 

No internal auditory canal or cerebellopontine angle masses. Subtle hyperintensity in the left jugular bulb may represent slow flow. No discrete thrombus identified. In the setting of headaches, MRV may be considered if venous thrombosis is of clinical concern. 

No air-fluid levels within the paranasal sinuses. 

No extraaxial collections or hemorrhage. 

Cerebral hemispheres and deep nuclei are without hemorrhage, mass or edema. 

Calvarium is intact. 

No Chiari malformation. 

Mamillary bodies are intact. No vermian or hemispheric cerebellar atrophy. Nigral and pallidal iron stores are maintained. 

Brainstem and cerebellum are without hemorrhage, mass or edema. No enhancing parenchymal masses. No abnormal meningeal enhancement. 

Mild temporal greater than frontal parietal atrophy with preservation of hippocampal volume. 

No siderosis or evidence of axonal injury. No abnormal enhancement within the descending 7th nerve complexes. No internal auditory canal or cerebellopontine angle masses. 

No temporal tip or subfrontal gliosis or encephalomalacia. 

Subtle hyperintensity within the left jugular bulb may represent slow flow. 

CONCLUSION: 

1. No acute parenchymal or extraaxial hemorrhage. No supportive findings of axonal injury. No subfrontal or temporal tip encephalomalacia. 

2. Mild temporal atrophy with relative preservation of the hippocampal volume. 

3. No obstructive hydrocephalus. No NPH. 

4. No supportive findings of multisystem atrophy. 

5. No acute supra- or infratentorial ischemia or demyelination. 

6. Subtle hyperintensity in the left jugular bulb may represent slow flow. No discrete thrombus identified. In the setting of headaches, MRV may be considered if venous thrombosis is of clinical concern. 

7. Cystic sellar mass with differential which may include pars intermedia cyst, craniopharyngioma, cystic adenoma. Endocrine function testing, pituitary-focused MRI with and without contrast may be considered to provide further definition. 

ADDENDUM: 

Examination is re-reviewed with additional pituitary focused images. T2 hyperintense lesion within the central and right sella measuring approximately 1cm x 0.8cm x 0.9cm with an intracystic mural nodule, which is hyperintense on nonenhanced T1 images without postcontrast enhancement. There is subtle uplifting of the right supracavernous carotid. Lesion abuts the right cavernous carotid without frank right-sided cavernous sinus invasion. 

Pituitary stalk is deviated to the left. No abnormal enhancement or nodularity of the pituitary stalk. Sella is slightly enlarged. The pituitary height of approximately 7.8mm is greater than 1 standard deviation above the mean for patient age. Soft tissue displacement from right to left within the sella. 

No abnormal meningeal enhancement. 

CONCLUSION: 

Intrasellar cystic mass with nonenhancing T1 hyperintense mural nodule. Differential may include Rathke cleft cyst, craniopharyngioma, cystic adenoma. CT may be considered as presence of calcification would favor craniopharyngioma over Rathke cleft cyst. Particular patterns of endocrine disturbance could be characteristic of adenoma, and endocrine function testing is recommended.

LESSON 2, TOPIC 69

Case Challenge: Sella MRI Cases

Case Challenge

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Content reviewed: July 15, 2021

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