Craniopharyngioma Imaging

Overview

Craniopharyngioma is a histologically benign, extra-axial, slow-growing tumor that predominantly involves the sella and suprasellar space (see the images below).

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Contrast-enhanced T1-weighted image demonstrates a complex cystic mass (arrow) in the suprasellar space.

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Axial contrast-enhanced CT scan in a 65-year-old man demonstrates a large, calcified suprasellar mass with anterior displacement of the A1 segment of ....

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Contrast-enhanced T1-weighted image in a 66-year-old woman (same patient as in following image) obtained in a slightly lateral parasagittal plane demo....

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Sagittal nonenhanced T1-weighted image demonstrates a heterogeneous, cystic mass (arrows) in the suprasellar space (same patient as in previous image)....

Despite its histologic appearance, craniopharyngiomas occasionally behave like malignant tumors. They can metastasize, and patients can have severe symptoms that usually require surgery and/or radiation therapy (with intracystic chemotherapy in some pediatric patients). Recurrences, both local and along surgical tracts, have been reported, as has meningeal seeding. Characteristic radiographic findings help in differentiating craniopharyngiomas from other tumors that can occur in the same anatomic region. Zenker first described craniopharyngioma in 1857.^{[1, 2, 3, 4, 5]}

Preferred examination

CT and MRI are the complementary examinations of choice.^{[6, 7]} Today, the best imaging tool is MRI, both with and without contrast enhancement. CT can clearly demonstrate the characteristic calcifications and size of the tumor, whereas MRI exquisitely demonstrates the size and extent of the tumor and involvement of the third ventricle. MRI results can confirm cystic features of the tumor. Sequences such as fluid-attenuated inversion recovery (FLAIR), gradient-echo (GRE) imaging, and diffusion-weighted imaging, as well as MR spectroscopy, can be used to make a confident and correct diagnosis.^{[8, 9, 10]}

Plain radiography may show abnormalities; however, CT or MRI is still needed regardless of the plain radiographic findings. CT and MRI have supplanted angiography as the primary diagnostic modality; today, magnetic resonance angiography (MRA) or CT angiography (CTA) may be helpful in differentiating the tumor from an aneurysm of the anterior communicating artery.

In the later postoperative period, CT can be performed to establish the baseline for future follow-up scans and to determine the number and size of residual flecks of calcification. In the immediate postoperative period (first 48 h) and later, gadolinium-enhanced MRI may be performed to establish a baseline appearance and to determine whether residual tumor is present.^{[11, 12, 13, 14, 15, 16, 17, 18, 19, 20]}

Nonenhanced CT may be required to detect calcifications if typical MRI findings are absent. A papillary-type lesion can be missed on MRI or CT when no characteristic cystic component is present or when lesions are not enhanced after the administration of intravenous (IV) contrast material (as occurs in approximately 10% of patients).

Limitations

MRI cannot be used in patients with pacemakers or implanted ferromagnetic metallic objects or in those with metallic foreign bodies in the brain, spinal cord, or soft tissues near important vascular structures. The use of MRI also is limited in patients with claustrophobia and in those who are unable to remain stationary for the required time. Both CT and MRI evaluations require IV contrast enhancement; therefore, IV access is needed.

Failure to make the diagnosis is a pitfall because tumor calcifications on CT may be misinterpreted as enhancing aneurysms, and correlation with cerebral angiographic findings may be needed to differentiate the 2 entities. In addition, calcifications appear as signal voids on MRI and can be misinterpreted as aneurysms. MRA should be performed in questionable cases.

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

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Radiography

A lateral radiogram of the skull may demonstrate calcifications in either the sella turcica or suprasellar space (see the first image below), or it may demonstrate sellar expansion or erosion of clinoid process or dorsum sella (see the second image below).

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Digital radiograph in a 23-year-old woman demonstrates characteristic calcifications (arrow) in the suprasellar space. This appearance can easily be m....

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Digital radiograph in a 39-year-old man demonstrates characteristic expansion of the sella turcica (arrows).

These calcifications can be confused with curvilinear calcifications observed with large aneurysms (occasionally referred to as eggshell calcifications). An aneurysm may be differentiated on contrast-enhanced CT, which demonstrates characteristic enhancement of the remainder of the lumen of the aneurysm, and on MRI, which shows heterogeneity of signal intensity and misregistration artifact from turbulent or pulsatile flow in the aneurysm. MRA further helps to elucidate the diagnosis in questionable cases.^{[2, 12, 13, 14, 16, 21]}

The degree of confidence for a negative result is low because small calcifications can be missed easily. When observed, calcifications are a nonspecific finding. Soft tissue visualization on plain radiography is poor; therefore, differentiation of the type of tumor present is not possible without further imaging.

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Computed Tomography

On CT, the adamantinomatous-type tumor appears as a predominately cystic mass (see the image below) with a solid component (>90%).

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Axial CT scan in a 39-year-old man (same patient as in the following image) obtained without contrast enhancement demonstrates a large, cystic mass (a....

The solid component appears isoattenuating and usually contains calcifications (>80%). The sella may be expansile, and hydrocephalus may be present, depending on the exact location of the tumor. Tumors of the papillary type are usually solid and isoattenuating; they are rarely calcified. Occasionally, craniopharyngioma may appear as an intraventricular, homogeneous soft tissue mass without calcifications but possibly with hypoattenuating regions; this is observed in the papillary subtype.^[14]

The location of the adamantinomatous subtype is characteristic because most are located in the sella or suprasellar region. Contrast enhancement is characteristic of the solid component (see the first image below) and cyst wall (90% cases), and an enhanced study may demonstrate displacement of the A1 segment of the anterior cerebral artery (see the second image below). Displacement of the optic chiasm also may be observed.

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CT scan in a 39-year-old man (same patient as in the previous image) obtained with intravenous contrast agent shows enhancement of the anterior, solid....

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Axial contrast-enhanced CT scan in a 65-year-old man demonstrates a large, calcified suprasellar mass with anterior displacement of the A1 segment of ....

On CT, the cystic component of the tumor extends anteriorly and/or laterally and typically wraps around the solid component. Conversely, the solid component characteristically extends posteriorly and laterally.

The degree of confidence is high because CT is sensitive for calcifications and for visualizing the cystic nature of masses. As with MRI, the noncalcified, papillary variant may sometimes be missed. A Rathke cleft cyst is rarely calcified, whereas more than 90% of craniopharyngiomas are calcified.

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Magnetic Resonance Imaging

On MRI, the more common adamantinomatous subtype appears as a predominately cystic suprasellar mass with a solid component (see the image below). Characteristic calcifications may not be discernible, though gradient-echo (GRE) images may show susceptibility effects from calcified components. Cystic areas appear hyperintense on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images with heterogeneous isointense to hypointense solid components.^{[12, 14, 16, 18, 22, 8]}

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Contrast-enhanced T1-weighted image demonstrates a complex cystic mass (arrow) in the suprasellar space.

Changes in signal intensity vary on T1-weighted images, depending on the cystic contents, which can appear hyperintense if they have a high protein, blood product, and/or cholesterol content in the classic adamantinomatous type. In the papillary variety, solid components appear isointense on T1-weighted images.

Magnetic resonance (MR) spectroscopy shows a prominent lipid spectrum (around 1 ppm) in terms of the cystic contents. Diffusion-weighted images demonstrate variable signal intensity, which reflects the cystic contents.

The sella may be expansile, and hydrocephalus may be present, depending on the exact location of the tumor. Compression of the third ventricle may occur; when present, such compression helps in distinguishing craniopharyingioma from Rathke's cleft cyst or pituitary adenoma. Occasionally, craniopharyngiomas appear as intraventricular, homogeneous, soft tissue masses without calcifications. They may contain regions of low signal intensity; this is observed in the papillary subtype.

Some craniopharyingiomas can be both intrasellar and suprasellar, having a "snowman" appearance.^[8] The location of the adamantinomatous subtype is characteristic, with most tumors located in the sellar or suprasellar region (see the images below).

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Coronal T1-weighted image in a 65-year-old man obtained through the sella turcica. Image demonstrates a predominantly sellar lesion (arrows) with some....

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Contrast-enhanced T1-weighted image in a 66-year-old woman (same patient as in following image) obtained in a slightly lateral parasagittal plane demo....

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Sagittal nonenhanced T1-weighted image demonstrates a heterogeneous, cystic mass (arrows) in the suprasellar space (same patient as in previous image)....

Contrast enhancement is characteristic (see the images below). MR angiography may demonstrate displacement of the A1 segment of the anterior cerebral artery; displacement of the optic chiasm may also be observed.

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Sagittal contrast-enhanced T1-weighted MRI demonstrates a complex cystic, suprasellar mass that is heterogeneously enhancing (arrow).

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Gadolinium-enhanced parasagittal T1-weighted MRI in a 23-year-old woman (same patient as in the previous image) demonstrates the characteristic enhanc....

On MRI, the cystic component of the tumor extends anteriorly and/or laterally and typically wraps around the solid component (see the images below).

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T1-weighted MRI of a 23-year-old woman (same patient as in the following 2 images) demonstrates a suprasellar mass with characteristic intermediate- t....

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Sagittal T1-weighted MRI in a 23-year-old woman (same patient as in the following image) demonstrates the high signal intensity of the cystic material....

Conversely, the solid component of the tumor characteristically extends posteriorly and laterally (see the image below).

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Axial contrast-enhanced T1-weighted MRI demonstrates enhancement of the solid component (arrows) of the lesion.

Adjacent brain parenchyma may show hyperintensity on T2-weighted or FLAIR images, which indicates edema from compression of optic chiasm and/or tracts, gliosis, or tumor invasion. Recurrence in both the local tumor bed and along surgical tracts may the result of implantation of craniopharyngioma tissue. Therefore, post-treatment MRI has been recommended, even in patients whose primary tumor was resected completely.^{[18, 8]}

The degree of confidence is high. Although MRI without a GRE sequence can be insensitive for calcifications, it is sensitive for determining the fluid or soft tissue content of a given area. False-positive results may occur as a result of misidentification of a similar lesion in the differential diagnosis.

A Rathke cleft cyst (RCC) can usually be differentiated because it is rarely calcified, whereas 64-92% of craniopharyngiomas are calcified. An RCC is also usually associated with anterior infundibular displacement and does not have a solid component. In addition, it shows contrast enhancement less frequently than other tumors do. Small RCCs may be indistinguishable from the rare intrasellar craniopharyngiomas.

A suprasellar arachnoid cyst has angular margins and is entirely cystic, with no solid component or enhancement.

Hypothalamic or chiasmatic astrocytomas arise at their respective locations and appear solid with areas of necrosis. The pilocytic variety may show cystic changes; however, calcification is less common with this tumor than with others. A moderate degree of enhancement may be seen.

Meningiomas demonstrate the dural tail sign, which is absent with craniopharyngiomas. Meningiomas also have a wide dural base and densely adhere to the dura. A craniopharyngioma can grow to more than 5 cm, but most are smaller. Conversely, a germinoma is almost always large, and its signal intensity and enhancement are homogeneous. A cystic component rarely is observed, and a pineal satellite lesion may be present.

Pituitary adenoma is rare in children; it is mostly intrasellar in the microadenoma variety. Macroadenomas may have suprasellar components with cystic, hemorrhagic, and enhancing areas; findings closely mimic those of a craniopharyngioma. However, calcification is rare.

Teratomas contain mixed solid and cystic components, as do craniopharyngiomas, but teratomas typically contain some fat.

Epidermoids can be distinguished by their characteristic scalloped margins and by the fact that, with epidermoids, there is minimal or no peripheral enhancement. Epidermoids are typically strongly hyperintense on diffusion-weighted images. Dermoids also contain a fatty component.

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Ultrasonography

With the wide availability and documented accuracy of CT and MRI, ultrasonography has not been accepted as a universal tool for the evaluation of pituitary masses. A few case reports have described the use of ultrasonography with color Doppler imaging in the antenatal diagnosis of fetal craniopharyngiomas. Adult craniopharyngiomas have also been evaluated with the use of color Doppler and ultrasonographic contrast agents.^{[14, 16, 19]} However, the modality is operator dependent, it can be limited because of beam attenuation by the bony skull vault, and lesions may be missed.

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Nuclear Imaging

Although evidence of increased metabolic activity in the tumor mass and surrounding brain has been observed, nuclear evaluation is not preferred for the diagnosis of craniopharyngioma.

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Angiography

Most of the findings relate to displacement of the cerebral vasculature secondary to mass effect. Specifically, the position of the anterior cerebral artery is well correlated with the location of the tumor. When the A1 segment of the anterior cerebral artery and the anterior communicating artery are in the usual position, the tumor is contained entirely or almost entirely within the sella.

When the A1 segment and the anterior communicating artery are elevated (see the image below) but the basilar artery is in the usual position, the tumor protrudes anteriorly and projects between the optic nerves, deviating the chiasm posteriorly. When the A1 segment and the anterior communicating artery are elevated and the basilar artery is displaced posteriorly, the tumor protrudes posteriorly and pushes the chiasm anteriorly. Stretching of the posterior communicating arteries also may be noted. An unreliable finding is a small, vascular blush in the region of the tumor.

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Angiogram obtained in the anteroposterior projection clearly shows elevations of the A1 segment of the anterior cerebral artery (arrows) and anterior ....

CTA and MRA have supplanted angiography as the primary diagnostic techniques, and angiography is now rarely needed to differentiate the tumor from an aneurysm of the anterior communicating artery.

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Author

Robert A Koenigsberg, MSc, DO, FAOCR, Professor, Director of Neuroradiology, Program Director, Diagnostic Radiology and Neuroradiology Training Programs, Department of Radiology, Hahnemann University Hospital, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Robert L DeLaPaz, MD, Director, Professor, Department of Radiology, Division of Neuroradiology, Columbia University College of Physicians and Surgeons

Disclosure: Nothing to disclose.

Chief Editor

James G Smirniotopoulos, MD, Chief Editor, MedPix®, Lister Hill National Center for Biomedical Communications, US National Library of Medicine; Professorial Lecturer, Department of Radiology, George Washington University School of Medicine and Health Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Mahesh R Patel, MD, Chief of MRI, Department of Diagnostic Imaging, Santa Clara Valley Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

Kiran Batra, MD, DNB Ne uroradiology Fellow, Radiology Resident, Drexel University College of Medicine

Kiran Batra, MD, DNB is a member of the following medical societies: American Roentgen Ray Society, Pennsylvania Radiological Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Christopher P Gange Jr, MA Drexel University College of Medicine

Disclosure: Nothing to disclose.

Jeffrey R Wasserman, DO Diagnostic Radiologist, Manatee Memorial Hospital and Lakewood Ranch Medical Center

Jeffrey R Wasserman, DO is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

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