Development of the pineal gland: measurement with MR.

PURPOSE: To use MR imaging in the analysis of the size of the normal pineal gland in infants, children, and adolescents. METHODS: We retrospectively analyzed the size of the pineal gland in 249 patients (129 male and 120 female) aged 2 weeks to 20 years old. The maximum length (L), height (H), and width (W) of the gland were determined from a combination of sagittal, coronal, and axial MR images obtained on a 1.5-T scanner. The volume was calculated by using the formula 1/2 x L x H x W. RESULTS: The size of the pineal gland was significantly smaller in patients younger than 2 years old than in older patients. The size of the pineal gland increased until 2 years of age and remained stationary between the ages of 2 and 20 years. We found a large variation in size among all age groups. No difference in size was noted between males and females. CONCLUSION: This study establishes norms for pineal gland size in infants younger than 2 years old and in children and adolescents 2 to 20 years old as detected with MR imaging. Knowledge of the size of the normal pineal gland is important in the detection of abnormalities of the pineal gland, particularly neoplasms.

Hypothalamic and pituitary pathology.

This article details the intricate anatomy and elegant physiology of the hypothalamic-pituitary axis. The discussion is meant to confer an understanding of the principles of neuroendocrinology appropriate for the radiologist interpreting imaging studies of this region. The clinical presentations of the diseases that occur in this area of the central nervous system are unique and therefore are discussed in some detail. The radiologic features of the diseases affecting the hypothalamic-pituitary axis are described and correlated with the relevant pathology.

Thickened pituitary stalk on MR images in patients with diabetes insipidus and Langerhans cell histiocytosis.

The MR images of four female patients with acute onset of central diabetes insipidus and pathologically confirmed Langerhans cell histiocytosis were evaluated retrospectively for evidence of lesions in the hypothalamic-pituitary axis. The examinations were conducted on a 1.5-T MR system with thin-section sagittal and coronal T1-weighted (short TR/short TE) and T2-weighted (long TR/long TE) images. Three patients underwent T1-weighted MR after IV administration of gadopentetate dimeglumine. Compared with 20 normal subjects who were evaluated with the same MR protocol, three of the four patients had a symmetrically thickened pituitary stalk that demonstrated homogeneous signal enhancement following contrast administration. The high signal intensity of the posterior lobe, which was seen in normal subjects on T1-weighted sagittal images, was absent in all four patients. Two patients had associated abnormalities on either chest films or imaging studies of the temporal bone and two patients had isolated CNS Langerhans cell histiocytosis. The combination of a thickened pituitary stalk and absent posterior pituitary hyperintensity, while nonspecific for Langerhans cell histiocytosis, should nevertheless prompt further studies, such as chest films, bone scanning, or temporal bone CT, to attempt to narrow the differential diagnosis. Gadopentetate dimeglumine, in particular, may be a useful adjunct in the MR examination of the patient with diabetes insipidus.

Three-dimensional gradient-recalled MR imaging as a screening tool for the diagnosis of cervical radiculopathy.

The purpose of the study was to implement and assess a fast-screening, three-dimensional Fourier transformation (3DFT) MR sequence for the cervical spine. This sequence maintains adequate signal-to-noise and image contrast similar to gradient-recalled echo two-dimensional Fourier transformation (2DFT) imaging. Thirty patients with radiculopathy were examined with 3DFT gradient-recalled echo imaging. The data set consisted of 60 contiguous 1.5- to 2.0-mm-thick axial slices with a total coverage of 9 to 12 cm. In 10 patients, comparison was made with 4-mm-thick axial T1-weighted spin-echo 2DFT or gradient-recalled echo 2DFT studies. With the use of a volume acquisition, adequate signal-to-noise and image contrast similar to T2-weighted gradient-recalled echo 2DFT acquisitions were obtainable. Coverage was improved despite the use of thinner sections without interslice gap. Thin-section 3DFT provided superior detail of acquired foraminal and spinal canal stenosis and disk morphology. Limitations included increased sensitivity to patient motion and "wraparound" artifact in the slice-select direction. Overall, diagnostic confidence was improved with 3DFT owing to the reduction of partial volume artifact. We have adopted this technique as the primary screening method for diagnosing cervical radiculopathy.

Three-dimensional gradient-recalled MR imaging as a screening tool for the diagnosis of cervical radiculopathy.

The purpose of the study was to implement and assess a fast-screening, three-dimensional Fourier transformation (3DFT) MR sequence for the cervical spine. This sequence maintains adequate signal-to-noise and image contrast similar to gradient-recalled echo two-dimensional Fourier transformation (2DFT) imaging. Thirty patients with radiculopathy were examined with 3DFT gradient-recalled echo imaging. The data set consisted of 60 contiguous 1.5- to 2.0-mm-thick axial slices with a total coverage of 9 to 12 cm. In 10 patients, comparison was made with 4-mm-thick axial T1-weighted spin-echo 2DFT or gradient-recalled echo 2DFT studies. With the use of a volume acquisition, adequate signal-to-noise and image contrast similar to T2*-weighted gradient-recalled echo 2DFT acquisitions were obtainable. Coverage was improved despite the use of thinner sections without interslice gap. Thin-section 3DFT provided superior detail of acquired foraminal and spinal canal stenosis and disk morphology. Limitations included increased sensitivity to patient motion and "wraparound" artifact in the slice-select direction. Overall, diagnostic confidence was improved with 3DFT owing to the reduction of partial volume artifact. We have adopted this technique as the primary screening method for diagnosing cervical radiculopathy.

Gd-DTPA-enhanced MR imaging of pituitary adenomas.

Eleven previously nonoperated patients with suspected pituitary microadenomas were scanned on a 1.5-T GE system before and after administration of IV gadolinium-DTPA (0.1 mmol/kg). Six patients had Cushing disease, four had hyperprolactinemia, and one had acromegaly. Surgical confirmation was available in all cases, and these findings were correlated with results of CT and venous sampling, when available. The normal pituitary gland, infundibulum, and cavernous sinuses enhance immediately after the administration of gadolinium-DTPA, allowing contrast between the enhancing normal glandular tissue and low-intensity microadenomas. Contrast-enhanced MR detected a lesion not seen on the unenhanced images in two patients with Cushing disease and in one patient with hyperprolactinemia. Tumor delineation was improved with gadolinium administration in two additional cases. In six patients, administration of gadolinium did not significantly alter the precontrast interpretation. Adenomas were found at surgery in all 11 patients. The tumor was correctly localized on MR in four of the six patients with Cushing disease, resulting in an accuracy of 66.7%. In another patient, although a focal lesion was detected on MR, location of the adenoma at surgery was discrepant with the MR findings and was therefore considered a false-positive study. In the single false-negative examination, both pre- and postcontrast MR failed to detect a surgically confirmed microadenoma suspected on both contrast-enhanced CT and venous sampling. Correct localization of the adenoma was achieved in all of the five non-Cushing patients, yielding an accuracy of 100%. Immediate T1-weighted coronal scans were most useful in detecting intrasellar disease. Delayed scans obtained 30 min after injection did not improve the differentiation of pituitary gland from microadenoma.(ABSTRACT TRUNCATED AT 250 WORDS)

MR of aqueductal stenosis: evidence of a broad spectrum of tectal distortion.

The MR scans of 18 patients with nontumoral aqueductal stenosis and six patients with neoplastic stenosis of the aqueduct were reviewed in order to document and understand the variable appearance of the aqueduct and periaqueductal region on MR. The mesencephalic tectum is often distorted in patients with benign aqueductal narrowing. This distortion results in a number of different MR appearances ranging from an elongated and thin to a short and broad tectum. When compressed by a dilated suprapineal recess, the distorted tectum is sometimes difficult to differentiate from the bulbous enlargement caused by a tectal glioma. Patients in whom distortion of the tectum is the result of hydrocephalus and aqueductal stenosis should be recognized to avoid unnecessary diagnostic procedures and misdiagnosis.

Posterior fossa hemangioblastomas: MR imaging.

The magnetic resonance (MR) imaging findings of 18 surgically proved posterior fossa hemangioblastomas (15 patients) were retrospectively analyzed and correlated with computed tomographic (ten patients) and angiographic (eight patients) findings. Thirteen tumors were located in the cerebellar hemisphere, three in the vermis, and two in the medulla with associated syrinxes. Three patients had von Hippel-Lindau disease, two of whom had multiple cerebellar hemangioblastomas. Seven hemangioblastomas appeared as solid tumors, six as solid masses with central cysts, and five as cysts with mural nodules. Abnormal tumor vessels, with characteristic signal void, were demonstrated in 13 tumors. Associated hemorrhage was present in four tumors. Although angiography is usually required for the diagnosis and preoperative assessment of this tumor, MR imaging demonstration of a posterior fossa mass with abnormal vessels should suggest the diagnosis of hemangioblastoma. Moreover, the combination of a peripheral posterior fossa cyst with a mural nodule supplied by enlarged vessels may be pathognomonic.

Intradural spinal cord lesions: Gd-DTPA-enhanced MR imaging.

Twenty-five patients with suspected spinal cord neoplasms were studied with high-field-strength magnetic resonance (MR) imaging (1.5 T) before and after administration of gadolinium diethylenetriamine-pentaacetic acid (DTPA) (gadopentetate dimeglumine). Five patients had enhancing, nonneoplastic lesions, including spinal dural arteriovenous fistulas (AVFs), cord infarction, and chronic arachnoiditis. Fifteen patients had proved spinal cord neoplasms, 13 intramedullary and two extramedullary. Four of the intramedullary tumors were detected only after Gd-DTPA administration; in five others, contrast material enhancement improved observer confidence. Gd-DTPA also demonstrated one dural AVF not detected on precontrast images. Regions of cord ischemia or infarction related to spinal dural AVF also enhanced in three patients. Advantages of Gd-DTPA include the demonstration of small isointense intramedullary tumors and the ability to permit differentiation of tumor from adjacent cord syrinx and solid tumor from postoperative gliosis and arachnoid scarring. Gd-DTPA enhancement is a useful adjunct to high-resolution MR imaging of the spinal cord.

High-resolution MR imaging of pituitary microadenomas at 1.5 T: experience with Cushing disease.

The MR images of 27 patients with clinically and biochemically suspected Cushing disease were evaluated retrospectively in a blinded fashion. The MR interpretation was compared with detailed operative diagrams and operative and pathologic reports. The examinations were performed on a 1.5-T MR system with thin-section sagittal and coronal T1-weighted (short TR/TE) images. Each pituitary half was considered separately (54 "halves"). Twenty-one pituitary halves were considered to have glandular abnormalities on MR. Compared with surgical findings, 17 MR findings were true positives and four were false positives (one pars intermedia cyst, three normal tissue). Of the 33 pituitary halves considered normal on MR, 26 were true negatives and seven were false negatives. MR had an overall sensitivity of 71% and a specificity of 87% for these adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. A focal glandular hypointensity identified on coronal images was the most sensitive predictor of adenoma location. Sagittal images were not useful in either detection or localization. Upward convexity of the gland and deviation of the stalk were less useful indicators. Abnormalities of the sellar floor were the least reliable. In comparison with the capabilities of CT detection of microadenomas described in the current literature, it appears that high-field thin-section MR of the sella is the most sensitive imaging method for preoperative localization of ACTH-secreting adenomas in patients with Cushing disease.

Histochemical characterization and functional significance of the hyperintense signal on MR images of the posterior pituitary.

MR imaging of the pituitary fossa characteristically shows a well-circumscribed area of high signal intensity in the posterior lobe on T1-weighted images. We used a combination of high-field MR, electron microscopy, and histologic techniques in experimental animals to determine whether the hyperintensity of the posterior lobe might be functionally related to hormone neurosecretory processes, and to attempt to establish its chemical nature. Histologic sections of a dog's pituitary gland processed with lipid-specific markers showed intense staining in the posterior lobe but not in the anterior lobe, thus documenting the location of fat in the posterior pituitary. Administration of vasoactive drugs known to influence vasopressin secretion to anesthetized cats produced changes in the volume of high-intensity signal in the posterior pituitary. Subsequent electron microscopy showed a significant increase in posterior lobe glial cell lipid droplets and neurosecretory granules in dehydration-stimulated cats. The data suggest that the pituitary hyperintensity represents intracellular lipid signal in the glial cell pituicytes of the posterior lobe or neurosecretory granules containing vasopressin. The volume of the signal may, in turn, reflect the functional state of hormonal release from the neurohypophysis.

MR imaging of cavernous sinus involvement by pituitary adenomas.

The ability of high-resolution MR imaging (1.5 T) to detect invasion of the cavernous sinuses by pituitary adenoma was determined through a retrospective review of 74 patients. These patients were divided into three groups: 25 normal subjects, 24 subjects with invasive pituitary adenomas, and 25 subjects with noninvasive pituitary adenomas. A fourth group of 30 patients, who subsequently underwent surgery for pituitary adenoma, was evaluated prospectively by MR for the presence or absence of cavernous sinus invasion. Several features were analyzed: (1) the detectability of the medial and lateral dural margins of the cavernous sinus (2) the size and variation in intensity of compartments within the cavernous sinus (3) the relationship of endocrine function to the surgical and MR appearance of the cavernous sinus and (4) carotid artery displacement or encasement by tumor. The normal cavernous sinuses were usually symmetric, but their sizes varied. The lateral dural margin of the cavernous sinus was always recognized on MR as a linear, discrete, low-intensity area. The medial dural margin (pituitary capsule) was seen on MR in only two of the 25 normal patients. In all 24 patients with cavernous sinus invasion involvement was unilateral and was most common with laterally positioned prolactin or adrenocorticotropic hormone secretory adenomas. Invasion of the cavernous sinus was suspected by MR in only two of the 13 invasive microadenomas and was questionable in three. In 10 of the 11 macroadenomas with surgically proved dural invasion, MR demonstrated an asymmetric increase in size and intensity of the superior and inferior cavernous sinus compartments. Noninvasive macroadenomas compressed and displaced the cavernous sinus bilaterally. The prospective MR evaluation of 30 patients undergoing surgery for pituitary tumor revealed a sensitivity for predicting cavernous sinus invasion of 55%, a specificity of 85.7%, a positive predictive value of 62.5%, and a negative predictive value of 81.8%. No feature permitted certain distinction between invasive and noninvasive microadenomas, as the medial dural wall of the cavernous sinus could not be reliably identified. The most specific sign of cavernous sinus invasion was carotid artery encasement.

Posterior pituitary ectopia: an MR feature of pituitary dwarfism.

Using high-field-strength, 1.5-T, high-resolution MR, we identified the following complex of neurohypophyseal abnormalities in each of five pituitary dwarfs: (1) severe hypoplasia or total absence of the infundibulum; (2) absence of the posterior pituitary bright spot in its normal location; and (3) a 3-8-mm tissue nodule at the median eminence exhibiting lipidlike signal on T1-weighted images. On the basis of its signal features and the clinical absence of diabetes insipidus in these patients, the median eminence nodule appears to represent an ectopic and functional posterior pituitary gland. We propose that this anatomic derangement is the end result of a localized defect of developmental origin, possibly ischemic in nature, and involving principally the infundibular stem. Thus, human growth hormone deficiency could result from perinatal disruption of the peri-infundibular hypophyseal portal system, which in turn impairs anterior pituitary function through deprivation of direct delivery of crucial hypothalamic-releasing factors. Finally, we suggest that the trophic influence of continued axonal neurosecretion at the median eminence engages proliferation of rest cell pituicytes; a process that induces formation of an ectopic and functional posterior pituitary gland, complete with its characteristic bright spot.

Chordomas: MR imaging.

Twenty histologically verified intracranial and upper cervical chordomas were retrospectively studied with both magnetic resonance (MR) imaging and computed tomography (CT), and the advantages of each modality were compared with regard to three criteria: detection of tumor, delineation of extent of tumor, and characterization of tumor. MR imaging and CT were equivalent in permitting the detection of chordomas. MR imaging was considerably better in delineating the full extent of the tumor, which would influence establishment of treatment. MR imaging also provided a degree of histologic specificity that would be useful in prognosis.

Localizing studies in patients with persistent or recurrent hyperparathyroidism.

Preoperative localizing studies are essential for patients with persistent or recurrent hyperparathyroidism requiring reoperation, because of loss of normal tissue planes and because the hyperfunctioning parathyroid tissue that remains is more likely to be situated in an ectopic position. The value of noninvasive and invasive localizing techniques was evaluated in 59 consecutive patients undergoing reoperation for persistent (40 patients) or recurrent (19 patients) hyperparathyroidism. Magnetic resonance imaging was performed in 17 patients; 11 results (65%) were positive, 3 (18%) were negative, and 3 (18%) were false-positive. Ultrasonography was performed in 52 patients; 29 (56%) were positive, 16 (31%) were negative, and 7 (13%) were false-positive. Computed tomography was performed on 41 patients; 19 (46%) were positive, 16 (39%) were negative, and 6 (15%) were false-positive. Thallium chloride 201-technetium 99m pertechnetate scans were used in 39 patients; 19 (49%) were positive, 11 (28%) were negative, and 9 (13%) were false-positive. One or more of these noninvasive tests was positive in 78% of the cases. Highly selective venous catheterization with measurement of immunoreactive parathyroid hormone concentration localized the abnormal parathyroid gland in 20 of 28 patients (71%) overall and in 8 of the 14 patients (57%) whose tumors were not identified by the noninvasive techniques. Since false-positive results were common, a combination of localizing studies was helpful in identifying the abnormal gland. Fifty-three of the 59 patients (90%) were successfully treated at the initial reoperation and three were successfully treated at a second reoperation. Advances in parathyroid localization have contributed to the improved surgical results in patients with persistent or recurrent hyperparathyroidism.

Posterior pituitary gland: appearance on MR images in normal and pathologic states.

T1-weighted magnetic resonance (MR) images of the pituitary gland and sella turcica routinely demonstrate a region of high signal intensity in the neurohypophysis. High-resolution MR imaging studies of the sella turcica in 200 subjects with a normal or abnormal sella were analyzed. The hyperintensity was found in the images of about 90% of healthy subjects and patients with microadenoma, in only 43% of patients with macroadenoma, and in 12% of patients with empty sellae. The signal was absent in several patients with functional or anatomic abnormalities of the hypothalamic-hypophyseal axis. It is concluded that the high signal intensity in the posterior lobe of the pituitary gland is present in most healthy individuals and that its absence in many patients with large intrasellar masses and empty sellae is due to compression of posterior lobe tissue. Its absence in diabetes insipidus further suggests a relationship between hyperintensity and the functional status of the hypothalamic-hypophyseal axis.

Rathke cleft cysts: CT, MR imaging, and pathologic features.

The authors retrospectively reviewed the clinical, computed tomography (CT), and magnetic resonance (MR) imaging findings in seven patients with pathologically proved Rathke cleft cysts. All the cysts were located in the anterior sella turcica or the anterior suprasellar cistern. Five cysts had both intra- and suprasellar components, one was entirely intrasellar, and the other was predominantly suprasellar in location. The size of the cysts ranged from 8 to 20 mm. CT scans demonstrated low-density homogeneous lesions in four cases. On MR images of three of these four cases, the cysts had the same intensity as cerebrospinal fluid on T1- and T2-weighted images, while in the fourth case, the cyst was hyperintense on the T1-weighted images. In the remaining three cases, CT showed slight hyperdensity relative to brain parenchyma, suggestive of contrast enhancement. MR showed signal heterogeneity of these lesions with focal components of diminished signal intensity of T2-weighted images. These same foci appeared iso- to slightly hyperintense on T1-weighted images.