5965
DECEMBER,
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THE
NEURORADIOLOGY PITUITARY WILLIAM
By
WEIDNER, M.D.,* LAWRENCE and WILLIAM HANAFEE, M.D4 LOS
T
HE
intimate
itary ventricle,
relationship
gland and
makes available. The
precise
review
the
to the major
purpose
of
plain
including
of the
delineation
pitu-
the
readily
authors
is to
roentgenographic
laminagraphy,
briefly
angiogra-
pneumoencephalograpituitary gland. Cavis a more recent technique will be deillustrative cases.
double jection of
an
intrasellar
exceptions sella floor giving rise
Plain
sulcus, of the
the
eter and inferior turcica because
passing
tangentially
separating sinuses.
the Multiple
essary to see nor view and
of the
diam-
boundary roentgen-ray
the
to
of
the
floor on anterior
the sella beam is
cortical
sella turcica projections the the
skull
anteroposterior
bone
and sphenoid may be necthe anteropostewall of the sella
turcica on the basal view. There are great variations in the normal size and configuration of the sella turcica. The diagnosis of pituitary tumors based on the size and configuration of the sella turcica
in the
absence
is unreliable.’ stant
of any
Furthermore,
relationship
and the determine
of the width
turcica, all be
tions tion ment *
f
which are are unreliable, may be Associate
Professor,
the
size of possible
of
the
the pituitary enlargement
the length, depth, and considered.6”#{176} Calcula-
on the lateral for asymmetric overlooked. The
projecenlargeso-called
Department
UCLA
NIH Fellow in Neuroradiology, Associate Professor, Department
of Radiology,
Center
may double
are
structures, sinus and
result
in
many
because the tilted slightly, in the lateral
such as the Ca-
a false
appear-
floor.’0
will
be
three the
necessary
in these
projections true size
are necessary of the sella and
projec-
configuration.’#{176}
Enlargement of the sella turcica may be due to intrasellar lesions, most commonly pituitary adenoma and less commonly craniopharyngiomas. Suprasellar or tuberculum sellae meningiomas may extend into the sella and cause enlargement. Unilateral enlargement of the sella turcica may be secondary to an intracavernous aneurysm of the internal carotid artery. Enlargement of the
sella
is also
seen
when
the
drocephalus in
and
is no consize
based
its
change
there
between
sella turcica gland.” To sella must
structural
There
When the boundaries of the sella turcica cannot be clearly delineated in lateral, anteroposterior and base projections, lamitions. The to determine
roentgenograms
indicate
tumor.
Other bony of the sphenoid
ance
LAMINAGRAPHY
lateral
readily
M.D.,f
to this observation may normally be to a double contour
rotid
ROENTGENOGRAPHY
AND
ROSEN,
THE
floor formation in a true lateral prois usually considered to be evidence
nagraphy PLAIN
OF
CALIFORNIA
projection. the walls
findings
carotid
phy, and fractional phy in tumors of the ernous sinus venography development and our scribed in detail with
ANGELES,
basal cisterns, third vascular channels
anatomic
OF TUMORS GLAND
the
dilatation
bulges Adenomas
arise
from
into
of
in patients
third the
anterior
system
gland
lobe
hy-
shares
ventricular
the sella. of the pituitary
the
with
ventricle
usually
and
are
either
chromophobe, eosinophilic, or basophilic. These can be differentiated roughly on the basis of the appearance of the sella turcica. The chromophobe adenomas grow rapidly and
to
considerable
size.
enlargement of the sella struction and demineralization walls. In addition, there for the Health
Sciences,
Department of Radiology, UCLA Center for the Health of Radiology, UCLA Center for the Health Sciences,
884
Los Angeles,
There
turcica are
is marked
with deof the bony no
California.
Sciences, Los Angeles, Los Angeles, California.
California.
skeletal
95,
VOL.
Tumors
No.
changes which Eosinophilic Downloaded from www.ajronline.org by 37.44.207.193 on 01/26/17 from IP address 37.44.207.193. Copyright ARRS. For personal use only; all rights reserved
tism
in
accompany adenomas
youth
and
these result
of the
acromegaly
gigan-
in
The
usually
are
well
well calcified Basophilic are usually obtain
outlines
of
defined
the
adults.
sella
and
turcica
the
margins
in the majority of cases.’3 adenomas, on the other hand, very tiny adenomas and rarely
sufficient
size
to
cause
any
enlarge-
ment of the sella turcica. These patients usually have Cushing’s syndrome and generalized skeletal demineralization may be present with a sella turcica of normal size. Calcification in pituitary adenomas is rare
and
than tion
5 to per cent.5 seen in chromophobe
in
probably
does
not
capsule
of
in
Curvilinear adenomas
‘
the
occur
the
tumor
or
more
calcificaoccurs
in
the
ANGIOGRAPHIC
FINDINGS
PITUITARY
Angiography being
frequently
in evaluating
the
reliability
extensions
of the
anterior
communicating,
of
pitu-
choroidal,
and
pos-
posterior
cere-
bra! arteries.2 When the tumor spills out laterally, it may extend under the temporal lobe and elevate the middle cerebral artery and basal vein of Rosenthal. Occasionally, medial displacement and elevation of the supraclinoid segment of the internal carotid artery
are
seen
with
this
type
of
extension.2
These changes are usually not observed unless the lateral extension is of considerable size. The sensitivity of carotid angiography is enhanced ous internal carotid
by bilateral simultaneartery injections in the
projection.
PNEUMOENCEPHALOGRAPHIC IN
CHANGES
PITUITARY
TUMORS
Ventriculography cause
the
is
suprasellar
unsatisfactory
be-
subarachnoid
cisterns
are
reported
as
boundaries
of the pituitary gland. The internal carotid artery can reflect lateral protrusions3 and, to some degree, suprasellar extension of tumors, especially if the growth is asymmetric. The variability of the vascular anatomy reduces
elevation
tenor
in
IN
the
suprasellar
anteroposterior
ADENOMAS
is
helpful
and
wall
of a cyst. The calcifications which occur eosinophilic adenomas are of a calcareous nature which have been called pituitary calculi.
88g
itary adenomas can be diagnosed angiographically if there are lateral displacement
They are slow growing tumors and the walls of the pituitary fossa mold to conform to the configuration of the slowly growing adenoma.
Gland
Posterior
tumors.’3
in
Pituitary
of angiography.’5
In
not filled. In the past, there was some reluctance to employ pneumoencephalography in patients with suspected pituitary tumors because of their tendency to hypotensive states. Replacement hormonal therapy, both
before
and
during
pneumoencephalog-
raphy by intravenous drip and the use of smaller quantities of air with the fractional technique have overcome the previous objections to this procedure. At
the
time
of pneumoencephalography,
addition, suprasellar extensions of pituitary tumors tend to grow in a dumbbell fashion and occasionally do not displace vessels. Anterior suprasellar masses can elevate the anterior cerebral arteries and cause posterior and inferior displacement of the supraclinoid segment of the internal carotid arteries. This has been referred to as closing
air must be directed into the ventricular system as well as the basal cisterns and,
artery
in
of the siphon. sion is directly
matic tricular inferior
cistern and only by filling the vensystem and outlining the anterior third ventricle can the true midline
When above
the suprasellar extenthe sella turcica, the
carotid placed
siphon laterally,
is usually The
internal
carotid
artery
been
called
opening
elevated appearance in
of the
these
carotid
and disof the cases
has
siphon.
specifically,
into
determine
if any
ists.’6
Cisternal
presence
Air will
or
become the
the
chiasmatic
suprasellar
air
will
absence
trapped lateral
of
cistern
to
extension
only
indicate
suprasellar
around recesses
the tumor.
the of
ex-
the
extension of the tumor be appreciated.9 so-called limited pneumoencephalogram not desirable because, occasionally,
carotid chias-
A is these
William
886
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tumors
may
spill
temporal lobe be determined cephalography curs
of
the
laterally
under
Rosen the
horn.
In
addition,
a dilated third ventricle turcica may be the cause
important
the
time
roentgenograms
to
of pneumoencephalogra-
the brow-up translateral roentwith and without autotomogra-
phy
the
central
beam
anterior third hyperextended
ventricle. in order
into
and
the the put
the
optic
centered
on
head direct
must the
The to
be air
recesses
of
to axis
of the
ANATOMY
infundibular
the
third ventricle. For autotomography, hyperextended position is essential the anterior third ventricle in the
of rotation
head
OF
INFERIOR
movement.12
THE
CAVERNOUS
PETROSAL
AND
SINUSES
Anatomically, the cavernous sinuses are the ideal structures by which to outline the dimension of the pituitary gland. The cavernous sinuses are paired, irregularly shaped, dural venous structures at the sides of the body of the sphenoid bone. They are united by the anterior and posterior i ntercavernous sinuses which complete the circle about the pituitary gland. The anterior extent of the cavernous siflus is junction tends
the superior with the posteriorly
pyramid trosal The
and
orbital ophthalmic to the
apex
is in continuity
fissure veins.
at It
of the
petrous
with
the
the ex-
pe-
lumen
strands.
of
and Enclosed
the
cavernous
divided in
by the
lateral
sinus
many
is re-
fibrous wall
sinus are the internal carotid artery, motor, trochlear, abducent nerves, ophthalmic and maxillary divisions trigeminal At the
Hanafee
TECHNIQUE
of
the
oculoand the of the
nerve.
posterior end of each cavernous sinus, the inferior petrosal sinus passes posteriorly, inferiorlv, and laterally and ends in the internal jugular vein, Its course is in
1965
DECEMBER,
OF
CAVERNOUS
VENOGRAPHY
Cavernous sinus venography is simpler than carotid angiography because (i) the brain is not perfused with contrast material; (2) the dangers of embolization of air bubbles and clots with resultant central nervous system damage do not exist when the venous system is injected; (3) no premedication is necessary and the examination can be performed on an outpatient basis; and (.) a low pressure vein is the site of puncture and there is little danger of hematoma. Basically, cavernous sinus venography is a refinement of retrograde jugularography.7 The usual sterile techniques are observed and a local anesthetic is injected in an area 3 fingerbreadths
above
the
medial
end
of the
clavicle, lateral to the palpable pulsations of the common carotid artery and medial to the edge of the sternocleidomastoid muscle. A 2-3 mm. nick is made in the skin with a No. I I Bard Parker scalpel blade to facilitate passage of the catheter. Puncture of the internal jugular vein is made with a 17 gauge thin walled Wickbom needle. A io cc. syringe filled with i per cent xylocaine is attached to the hub of the needle following the initial pass of the needle. Gentle suction is applied to the needle as it is withdrawn.
SifluSes.
ticulated
William
a groove between the petrous portion of the temporal bone and the basilar portion of the occipital bone. There may be considerable variation in the size of the inferior petrosal sinus on each side.4’8
lying of sel-
phy are genograms with
and
SINUS
lar enlargement. The most at
out
Lawrence
and this lateral extension can at the time of pneumoenby the deformity which octemporal
occasionally, in the sella
obtain
Weidner,
passage xylocaine aspiration injection
of
The
internal
ber
vein
ture.
In
posterior artery.
first then
If pain
the needle, can be injected to be certain is not made. jugular
which the
and
is elicited
vein
is a large
is relatively upper
lateral
Descending
accompanies the common
part
during
a small amount after preliminary an intravascular
easy of
the
neck,
to the
internal
through
the
to
of
calipuncit lies
carotid neck,
it
the internal carotid and carotid artery. As it de-
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VoL.
Tumors
No.
95,
I. Case I. Normal cavernous the left eye. (A) Basal view.
sinus
FIG.
sinuses;
4-inferior
catheter
in
4-inferior
venograms
sinuses;
5-partial
8-angular
view.
side arteca-
rotid
artery
the
Both
internal right
jugular as they
of
veins descend
the internal jugular to lie in front of the
angle and
the
neck.
slightly on the
to
the side
left
vein occasionall common carotid
comes artery.
the
moved for
needle.’4
from
The needle is then reguide wire and exchanged
a polyethylene
diameter ameter curved
of of
0.065
The
neuvered of
catheter
the
passage
with and with
an
of the
fluoroscopic
catheter
the
is necessary. a satisfactory
catheter
at
the
orifice
guide
wire fluoromaThe
the
of the of
of
3-cavernous
plexus;
6-right
jugular
vein;
3-cavernous
the
inferior
been 3-
7sinuses;
bulb;
catheters
are
ous sinus teropostenior
inserted
of
are
venography. without
basal.
anteropostenior
been
found Fig.
i,
is injected
i,
at the to
rapidly
patient
in
whom of the
prior
for
cavern-
nasion; tuncica;
and the
most
(i)
an. the
(2)
lat-
(,)
and
base
views
rewarding
B). Ten cc. of conray b hand into each cathexposed in a sequence of for 2 seconds. A prelimis
to
be
APPLICATIONS
largement
the sella
infe-
bilateral
positioned
utilized
be
noentgenogram
Opacification helpful in the
the
A and
eter and films are 2 films per second
SINUS
of
sides,
The’ are: tube angulation,
entering on
The
two
and
central ray eral, centering
inary
confirmed with a cc. of conray, the
sinus on the
to each injection for subtraction.
jug-
tip
has of
is taped to the skin. of the variable size
nor petrosal
(Case
to
position
for proptosis
sinuses;
ophthalmic
sinus injection
catheter Because
have
ular bulb, then rotated anteromediall\ to enter the inferior petrosal sinus. Horizontal beam fluoroscopy or occasionally a Waters’ projection with the portable image intensifier After
petrosal hand
outer dia slightly
control.
is advanced
pterygoid
I-superior
an internal
with horizontal beam catheter is subsequently
under the
inches inches
0.045
tip.
is monitored scopv and
tip
the
investigated
to the venograph\?. Three projections
When venous blood is aspirated from the \Vickbom needle, the s\’ringe is removed and a Seldinger type guide wire is inserted into
being
2-intercavernous
veins.
forward to the lateral and common carotid overlaps the common base
of
887
old female
vein;
filling
(B) Anteroposterior
Gland
year
40
ophthalmic
scends, it passes of the internal ries and finally in
Pituitary
in a
I-superior
petrosal
left jugular bulb. petrosal sinuses;
of the
OF
always taken used as a base
prior film
CAVERNOUS
VENOGRAPHY
of the following there sella
cavernous situations: is evidence turcica
and
sinus
is
(I)
A
of pneumo-
en-
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888
William
\Veidner,
Lawrence
Rosen
William
and
lI(.
Hanafee
(‘isc
n
ph
did
sd
Ii
n the
artery
nf
tue
is
interir
cern
Its
mm ills
cliii
of
IniomIlitel
the cavernous
portion
ternal lateral
of carotid
carotid angiogram. displacement of the
cerebral
arteries
arteries which is within be determined by carotid
cannot
can
be
compared
to
normal
limits.
It
delineation
so that the be planned
of
placement for the
eral extent of the precisel’ with this
(C)
iA.
with elevation
B.
the
time
Anternis)s_
sinuses;
the
tumor
defect
ir-
siphon;
portion of the the intrasellar
of
on
iliter-
bilateral
carotid
horizontal
miss
the
of
selective right
arterY
tiisjImcenient
Civerllnils Of
side,
iiidit
time
carotid
eratim.
6hing
extent
clint-
literal
nim
literal
Simultaneous
true
time
time
veil
ii
7-normal
of the
that
is apparent
8-
anterior tumor
angiography.
encephalographv reveals a normal ventricular system with no suprasellar mass (Case ii, Fig. 2, zI, B and C); and (2) the advent of cryohypoph ‘sec tom \ requires precise
Figure
Anteroposterior view. Compare left carotid siphon; 9-minimal
)rimm. ntr;iscl-
ot
iTredialile
simmic
of
vn(
ins
disj)PiCiim
to
The
side.
m sit
tilmmi(r
e\JinsIo
leit
nf
115 si
itid
Vie\\
I
cVldciicc
;
inch
terinr
cnccplni
c\tciisiMfl
sde
left
laterall
\\itli
iini]
iii
vcrn(
Li
c\ti15iMii ii
Pncii
hityiaI
I
nld
vir ci. mY
(/
.
iiiiss
d
ci
rcvciI
Vid\\
Pit
tn
nMt
mr miss.
liiI
l’ldrt
ii.
sl
1965
DECEMBER,
the
pituitary
tumor
of the cryoprobe specific tumor. The tumor can technique.
be
cations
extent of tumor of the sella is
delineated
delineation
beneath possible
the with
diathis
technique. William
can lat-
Precise
discussed.
are
of the phragm
Weidner,
M.D.
Chief Radiologist Harbor General iooo W. Carson Torrance,
Hospital Street
California
90509
J. D.
Roentgenologic
REFERENCES SUMMARY
The
neunoradiolog’
I.
of tumors
tuitary gland includes ph\’ and laminagraphy pneumoencephalograph’, ph’,
and
pertinent ties
carotid
cavernous
sinus
observations are
cavernous
reviewed sinus
of the
and venography
the
AM.
and
3.
its
666-674. E., and
ROENTGENOL.,
MED.,
N.
5961,86,
E.,
angiography
of appli-
CHASE,
sellar 214-224.
of
tumors.
and in
observations
sella
turcica.
of
conRadiology,
J. M. Cerebral
TAVERAS,
in diagnosis
J.
CLEAR
modali-
technique
53, N.
CHASE,
angiographv
The
these
erosion
1949, 2.
angiogra-
venographv. with
cerning
pi-
plain roentgenograof the sella turcica,
CAMP,
suprasellar
RAD.
tumors.
THERAPY
& Nu-
154-165. TAvERAS,
J.
M.
diagnosis of extradural .lcta radiol. (Diag.),
Carotid para1963,
I,
VOL.
Tumors
No.
95,
of the
Cunningham’s Textbook of Anatomy. Edited by J. C. Brash. Ninth edition. Oxford Medical Publications, London, 1953. 5. DEERY, E. M. Note on calcification in pituitary adenomas. Endocrinology, 1929, 13, 455-458. 6. Di CHIRO, G. Width (third dimension) of sella
Pituitary
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turcica.
J.
AM.
NUCLEAR
ROENTGENOL.,
MED.,
RAD.
84,
1960,
THERAPY
12.
Some
aspects Acta
on
radiol.,
technique 1949,
31,
i.
largement
C. Some of sella
1963,
152-163.
RADBERG,
RASMUSSEN,
I,
aspects turcica.
A. T. Quantitative
radiol.
en(Diag.),
SCH1NTZ,
14.
SELDINGER,
of human
1960,
74,
S. I. Catheter
replacement
of needle
in percutaneous
15.
i6.
arteriography: new technique. Ada radiol., 1953,39, 368-376. UDVARHELYI, G. B., LANGFITT, T. W., and Cox, A. Neuroradiologic diagnostic procedures in suprasellar space-occupying lesions with special
reference
to
Ada
radiol.
(Diag.),
WICKBOM,
radiologic suprasellar
study
Radiology,
autotomography.
H. R., BAENSCH, W. E., FRIEDL, E., and UEHLINGER, E. In: Roentgen Diagnostics. Edited by J. T. Case. Volume II. Grune & Stratton, Inc., New York, 1952.
13.
of 6i-
of asymmetric Acta
of
593-600.
‘77. 10.
SCHECHTER,
nic
1959.
E. encephalography.
1924,
visualization
GEJROT,
9. LINDGREN,
cerebri, or pituitary body. Endo8, 509-524. M. M., and JING, B.-S. Improved of ventricular system with tech-
crinology,
26-37.
T., and LINDBOM, A. Venography of internal jugular vein and transverse sinuses (retrograde jugularography). Ada oto-laryng., 1960, Suppl i8, pp. 180-186. 8. GRAY, H. Anatomy of the Human Body. Edited by C. M. Goss. Lea & Febiger, Philadelphia, 7.
889
hypophysis
4.
&
Gland
249-260.
I., and
angiographic 1963,
SHELDON,
diagnosis tumours.
of
Ada
measurements. I,
485-508.
P. Some posterior
radiol.,
aspects fossa 1953,
of and 40,
Downloaded from www.ajronline.org by 37.44.207.193 on 01/26/17 from IP address 37.44.207.193. Copyright ARRS. For personal use only; all rights reserved
This article has been cited by: 1. BIBLIOGRAPHY 376-393. [CrossRef] 2. Frank Doyle, Maurice McLachlan. 1977. Radiological aspects of pituitary—Hypothalamic disease. Clinics in Endocrinology and Metabolism 6:1, 53-81. [CrossRef] 3. Leon Morris, Ian Wylie. 1973. Tomography of the cavernous sinuses. The British Journal of Radiology 46:546, 424-426. [CrossRef] 4. M. Gado, J. W. D. Bull. 1971. The carotid angiogram in suprasellar masses. Neuroradiology 2:3, 136-153. [CrossRef]
