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Suprasellar mass ct scan of a child

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it is simple discussion for doctors doing post graduation in radiology. D/D is for proptosis esp. in paediatric age group

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Suprasellar mass ct scan of a child

  1. 1. SUPRASELLAR MASS: CT SCAN OF A CHILD Dr Rekha Khare MD Radiology
  2. 2. CLINICAL PRESENTATION  A male child of about eight months was brought by his parents to CT room for head CT scan  Parents noticed the bulging of left eye for few weeks  Vision was poor/ blind left eye  There was no other constitutional symptoms
  3. 3. CLINICAL EXAMINATION  Apparently child was found normal except PROPTOSIS Left eye  Routine laboratory exam were with in normal limit
  4. 4. COMMON CAUSES OF PROPTOSIS  V_ Vascular (arterio venous malformation)  E_ Endocrinal ( thyrotoxicosis )  I_ Infection/ Inflammation  N_ Neoplasm ( Primary/ Secondary ) ( Local/ Intracranial ) VEIN……
  5. 5. WHAT TO SEE ON CT SCAN?  eye ball  eye muscles ( extra ocular )  retro bulbar space  optic nerve  bony socket  adjoining paranasal sinus/ nasal cavity  intracranial tissue
  6. 6. PLAIN CT SCAN OF BRAIN
  7. 7. CONTD……..
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  19. 19. CONTRAST ENHANCED CT SCAN
  20. 20. CONTD…….
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  30. 30. CONTD………
  31. 31. CONTD……..
  32. 32. CT FINDINGS IN OUR CASE  An about 22x22mm hypodense globular mass, highly enhanced slightly heterogeneous in suprasellar region  Mass is extending to left frontal lobe and deepening the floor of sella  Mass is markedly entering to left orbital fossa through optic chiasma, encasing optic nerve sparing extra ocular muscles
  33. 33. DIFFERENTIAL DIAGNOSIS In contrary to adult age most common suprasellar tumor in child are with decreasing frequency …… : Craniopharyngioma :Chiasmatic/ Hypothalamic low grade glioma : Germinoma : Lesion attributed to langerhans cell histiocytosis
  34. 34. D/D SUPRA/ PARA/ INTRASELLAR MASS Satchmoe : nick name of “Louis Armstrong” 1. S: Sarcoidosis, sellar tumor 2. A: Adenoma, Aneurysm 3. T: Teratoma, Tubercular granuloma 4. C: Craniopharyngioma, Cyst-Rathke’s cleft 5. H: Hemartoma,Hypothalamic glioma 6. Histiocytosis 7. M: Metastasis 8. O: Optic nerve glioma, Germinoma 9. E: Epidermoid, Eosinophilic granuloma
  35. 35. CRANIOPHARYNGIMA Large intra and supra sellar mass with cystic& enhancing component as well as calcification in children are virtually pathognomonic for Craniopharyngioma…… perhaps with only Dermoid in the D/D **Our case shows no calcification at all
  36. 36. PATHOLOGICAL TYPE  Admantinomatous ….paediatric age group  Papillary…..Adult age group  Mixed……15%
  37. 37. EPIDEMIOLOGY  There is Bimodal age presentation with 1st peak between 10-14 age almost exclusively of Admantinomatous type  2nd peak young to middle aged mostly papillary sub type  Incidence about 6% of all expanding lesion in childhood
  38. 38. CLINICAL SIGNS/ SYMPTOMS  Increased intracranial tension (headache)  Endocrine dysfunction (Delayed puberty, short stature)  Visual problem
  39. 39. RADIOLOGICAL FEATURES  95% suprasellar, frequently distorting optic chiasma or compressing mid brain causing hydrocephalus  Occasionally intraventricular homogenous soft tissue mass with calcification commonly at 3rd ventricle
  40. 40. CT SCAN FINDINGS  Cystic near CSF density  Soft tissue density vivid enhancement  Calcification in 90% cases **calcification is uncommon in papillary variety
  41. 41. CHIASMATIC HYPOTHALAMIC GLIOMA  4-8% childhood intracranial tumor, rare in adults  Common in first decade less than 1yr  Male: Female incidence is equal  20-30% children are associated with neurofibromatosis  Progress rapidly
  42. 42. CH GLIOMA CONTD…..  Chiasmatic glioma can involve anything between optic nerve to visual cortex  Almost 25% optic pathways gliomas are confined to optic disc and nerve  40-75% may involve optic chiasma
  43. 43. CLINICAL SIGNS/ SYMPTOMS  Painless PROPTOSIS  Hydrocephalus if involving foramen of monro **HISTOLOGICALLY: Low grade Glioma
  44. 44. PITUITARY ADENOMA  Rarely present in children  Pituitary micro adenoma: less than 10mm in size  Pituitary macro adenoma: more than 10mm in size expansion of sella is common  Most pediatric pituitary adenomas present after the onset of puberty and present with frequent headaches, changes in visual acuity and, in females, menstrual dysfunction.  Most (19/20) were secretory, with prolactinomas being the most common type.
  45. 45. SUPRASELLAR MENINGIOMA  Benign tumor of meninges usually solid may contain necrotic/ cystic lesion and calcification  Frequently invade the sella turcica  Such tumor can also encase the optic nerve with in optic canal and fossa orbitalis
  46. 46. ARACHNOID CYST AND RATHKE’S CLEFT CYST  Rarely in suprasellar region in children  Clinical symptom: visual symptom, hydrocephalus, macrocephaly, pyramidal tract sign, precocious puberty
  47. 47. MISCELLANEOUS LESION A. Hypothalamic hemartoma: usually small and asymptomatic presenting in two decades Clinical symptom: hyperactivity syndrome with hyperplasia, behavior disorder, precocious puberty, gelastie seizure
  48. 48. CONTD…..  B. Lesion of INFUNDIBULUM: : Germinoma : Hypophysitis : Histiocytosis X
  49. 49. SUPRASELLAR GERMINOMA  20% of all Germ cell tumor  Hypo intense on T1, Hyper intense on T2 and extremely intense contrast enhancement  It can create diagnostic dilemma on imaging , can get easily confused with optic/ chiasmatic glioma.  If serum and CSF studies for tumor marker are negative , surgical exploration for biopsy and histological confirmation helps differentiation
  50. 50. FINAL DIAGNOSIS  Our probable diagnosis: Suprasellar germinoma OR Chiasmatic Hypophyseal Glioma  Patient was sent to advanced center for final diagnosis and further management  Unfortunately there was no feed back
  51. 51. CONCLUSION  Paediatric brain tumor have always been a challenge  They are heterogeneous set of pathologies involving different age groups in childhood and also differ widely from their adult counterparts as far as adjuvant therapies are concerned  Unlike Meningioma and Pituitary Adenoma in adults, Craniopharyngioma, Optic Glioma and Germinoma form the main lesions in paediatric age group
  52. 52. CONTD…..  While safe surgery is the Key in most of adult tumors, Chemo and Radiotherapy are the chief modality in some of these paediatric tumor like GERMINOMA and OPTICO- CHIASMATIC GLIOMA  As epidemiology and management of these tumors is different that’s why it requires dedicated multidisciplinary team approach
  53. 53. REFERENCES 1. Differential Diagnosis of suprasellar mass in children: Warmnth Metz M, Gnekow AK, Muller H, Solynosi L K.Klin Paediatri 2004 Nov Dec 216(6):323;30 2. Pituitary region mass: Dr Ayush Goel and Dr Frank Gaillard etal. Radiopaedia.org/article/Pituitary 3. Sella turcica and parasellar region: Walter Kucharezyk and Marieke Hazewinkel The Radiology assistant 4. Cranipharyngioma: Dr Frank Gaillard etal. Radiopaedia.org/article/craniopharyngioma
  54. 54. REF……CONTD. 5. Suprasellar Meningioma_ a case report: MG Kgoro, A Speclman The south African Radiographer vol.51 no 2 Nov 2013 6. Pituitary macro adenoma: Dr Henry Knipe and Yuranga W etal. Radiopaedia.orgt 7. Paediatric Suprasellar Lesion:. CE Deopujari, Ashish Kumar, VS Karmarkar, NK Biyani, M Mhatre and NJ shah Journal of Paediatric Neurosciences 2011 Oct(6 supple): 546-555
  55. 55. Thank you Have a good day

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