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MR Imaging Findings in Colloid Cysts of the Sellar Region

Posted Oct 31, 2013 Updated Apr 10, 2023
By Benjamin Bender MD , Jürgen B. Honegger MD , Rudi Beschorner MD , Ulrike Ernemann MD , Marius Horger MD
11 min read

Rationale and Objectives

To identify magnetic resonance (MR) imaging characteristics allowing specific preoperative discrimination between colloid cysts (CCs) of the sellar region and third ventricle (CC3rdv) versus Rathke’s cleft cysts (RCCs).

Materials and Methods

MR imaging data of 38 patients with histologically proven CCs/CC3rdv and RCC underwent retrospective analysis with respect to signal intensity and heterogeneity on T1- and T2-weighted images, presence of the dot sign, enhancement, size, location, and accompanying infundibular stalk abnormalities.

Results

Thirteen patients had CCs, 12 had CC3rdv, and 13 had RCCs. Signal intensity on T1-weighted images was partly or entirely hyperintense ( n = 8), iso- or mixed iso/hypointense ( n = 5) in CCs; hyperintense ( n = 8), isointense, or mixed hypo/isointense ( n = 3) in CC3rdv and hyperintense ( n = 9); or mixed ( n = 4) in RCCs. On T2-weighted images, signal intensity was hypointense ( n = 12) or hyperintense ( n = 1) in CCs, hypointense ( n = 9) or hyperintense ( n = 2) in CC3rdv, and hypointense ( n = 5) or iso/hyperintense ( n = 8) in RCCs. T2-weighted images were unavailable in two patients. Only one questionable enhancement was found in CCs, whereas an enhancing rim was consistently seen in RCCs. The dot sign was present in 7 CCs, 8 CC3rdv, and 4 RCCs. Mean cyst diameters were 12.6 mm for CCs and 14.5 mm for RCCs. RCCs showed more frequent and even solely suprasellar extent contrary to CCs.

Conclusion

Cyst wall enhancement was found in all RCCs but in none of the CCs, making this feature a reliable discriminator between the two. Complementary, suprasellar extension was more frequent in RCCs, whereas signal hypointensity on T2w was more common in colloid cysts.

Colloid cysts (CC) are benign, epithelial-lined mass lesions occurring in different locations, mostly attached to the anterosuperior aspect of the third ventricle between the columns of the fornices. Imaging features of CC of the third ventricle (CC3rdv) have already been reported and, because of their typical location, the spectrum of differential diagnoses is fairly restricted. Their magnetic resonance (MR) signal characteristics are dependent on the composition of the cyst content, in which T1-weighted signal correlates with cholesterol concentration (2/3 of them being hyperintense on nonenhanced T1-weighted images), whereas T2-weighted signal is variable. The latter reflects either water content (mostly isointense to the brain) or small amounts of paramagnetic substances contained in macrophages within CC (usually hypointense to the brain). Moreover, CC contain dense material of variable viscosity (mucoid or desiccated) intermixed with old blood, hemosiderin, cholesterol crystals, and various ions that seriously impact the MR signal. CC show no enhancement, not even in the cyst wall . The lining of CC3rdv is variable with stretches of cuboidal or flattened columnar epithelium that may alter with simple or pseudostratified epithelium.

Contrary to CC3rdv, the spectrum of differentials in case of CC of the sellar region (CCs) is more challenging. CCs are located between the anterior and posterior lobe of the pituitary gland and represent part of the so-called pars intermedia masses. Discrimination from other predominantly or entirely cystic masses such as Rathke’s cleft cysts (RCCs), arachnoid cysts, cystic adenomas, craniopharyngiomas, empty sella, pituitary necrosis, or some types of hypophysitis often proves difficult.

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Material and methods

Patient Characteristics

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Imaging

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Image Analysis

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Histologic Analysis

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Statistical Analysis

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Results

Demographics of Patients with CCs and RCCs

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Clinical Presentation of Patients with CCs and RCCs

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MR Imaging Characteristics in CCs

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Table 1

Magnetic Resonance Signal Characteristics in Patients with Colloid Cyst of the Sellar Region and Presence of Cyst Wall and Inflammation Within Cyst Wall in the Histology

Age Gender T1-weighted Hyperintense T2-weighted Hypointense FLAIR = T2 T1-weighted CE Mixed Signal Localization Cyst Wall Inflammation 50 F + + + +? + I + S + 0 48 F + + + 0 + I + S + 0 39 F 0 0 + 0 0 I + 0 30 M + + + 0 + I + 0 28 F 0 + + 0 0 I + S + 0 29 F + + + 0 0 I 0 0 27 F + + + 0 0 I + 0 27 F 0 + + 0 + I 0 0 18 M + + + 0 + I + 0 19 F + + + 0 0 I + S 0 0 12 F 0 + + 0 0 I + S 0 0 9 M 0 + NA 0 + I 0 0 23 F + + + 0 + I + S 0 0

0, not present; +, present; CE, contrast enhancement; cyst wall, presence of an identifiable cyst wall on magnetic resonance imaging; I, intrasellar; NA, no image available; S, suprasellar.

Figure 1, A 30-year-old male patient with sellar colloid cyst (CC). On the sagittal view (a) , an ellipsoid-shaped mass exhibiting three different signal intensities is shown between the anterior (x) and posterior limb (*) of the pituitary gland. On sagittal T2- (a) and axial T1-weighted image (b) , the outer part demonstrates a fluid-equal appearance ( arrowhead ), whereas the core is slightly hypointense on T2-weighted images and hyperintense on T1-weighted images ( circles ). Within the lesion's core, a spotted dot sign is present ( small arrows ). No enhancement is seen in the colloid cyst wall on postcontrast T1-weighted image (c) .

Figure 2, Typical and atypical colloid cysts on T2-weighted ( upper row ) and corresponding T1-weighted images ( lower row ) in coronal (a, b) or sagittal (c–f) orientation showing different imaging features. On T2-weighted images, large parts of the cysts are hypointense (a, b) , but not in (c) . Note signal iso- or hyperintensity on corresponding sagittal T1-weighted images (d, e) . Coronal postcontrast T1-weighted imaging shows no peripheral enhancement in colloid cysts that proved already hyperintense on nonenhanced T1-weighted imaging (e) .

Figure 3, Sellar colloid cyst with mixed signal intensity on T2-weighted (a) , nonenhanced T1-weighted (b) , and postcontrast T1-weighted (c) images. There is no contrast enhancement of the cyst boundaries ( white arrow ).

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MR Imaging Characteristics in CC3rdv

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Table 2

Magnetic Resonance Signal Characteristics in Patients with Colloid Cysts of the Third Ventricle and Presence of Cyst Wall and Inflammation Within Cyst Wall in the Histology

Age Gender T1-weighted Hyperintense T2-weighted Hypointense FLAIR = T2 T1-weighted CE Mixed Signal Cyst Wall Inflammation 56 M + + + NA + + 0 47 F NA + + NA + 0 0 40 F + NA NA 0 0 0 0 42 M + + + 0 0 + 0 45 M + + + 0 + + 0 38 F + + NA NA + + 0 31 M 0 0 + NA 0 + 0 31 F + + + 0 + 0 0 30 M + + + 0 + 0 0 59 M 0 + + 0 + + 0 32 F + + + 0 + 0 0 27 M 0 0 + 0 0 + 0

0, not present; +, present; CE, contrast enhancement; cyst wall, presence of an identifiable cyst wall on magnetic resonance imaging; NA, no image available.

Figure 4, A 32-year-old female patient with colloid cyst of the third ventricle. Note a typical dot sign (×) with central hypointensity on coronal T2-weighted image (a) and slight signal hyperintensity on axial nonenhanced T1-weighted images (b) . No contrast enhancement is seen on axial postcontrast T1-weighted image (c) .

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MR Imaging Characteristics in RCCs

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Table 3

Magnetic Resonance Signal Characteristics in Patients with Rathke Cleft Cysts and Presence of Cyst Wall and Inflammation Within Cyst Wall in the Histology

Age Gender T1-weighted Hyperintense T2-weighted Hypointense FLAIR = T2 T1-weighted CE Mixed Signal Localization Cyst Wall Inflammation 46 F + 0 + + 0 S + 0 52 F + + + + 0 I + S + + 56 F + + + + + I + S + 0 55 F 0 0 + + 0 I + S + 0 17 F 0 0 + + 0 I + S + + 46 M + 0 NA + 0 I + S + 0 68 M + 0 + + + S + + 21 F + + + + + I + S + + 45 F 0 0 + + 0 I + S + 0 32 F + 0 + + 0 I + + 14 F + + + + + I + S + P + + 46 F 0 0 + + 0 S + I + 0 57 M + + + + + S + I + +

Enhancement was in all cases seen at the rim of the cyst.

0, not present; +, present; CE, contrast enhancement; cyst wall, presence of an identifiable cyst wall on magnetic resonance imaging; I, intrasellar; NA, no image available; S, suprasellar.

Figure 5, A 60-year-old female patient with Rathke's cleft cyst. A large intrasellar mass with suprasellar extension is seen exhibiting a hyperintense signal on both coronal T2-weighted image (a) and sagittal T1-weighted image (b) . On sagittal postcontrast T1-weighted image, an enhancing rim (capsule) can be identified along the suprasellar border of the cyst ( c , arrows ).

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Histological Characteristics of CC and RCCs

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Figure 6, Histology of colloid cysts (CC) of the third ventricle (CC3rdv), CCs, and Rathke's cleft cysts (RCC). (a) Cyst wall of a CC3rdv. Note adjacent central nervous system tissue ( lower half ) and parts of the choroid plexus ( bottom left ). (b) Cyst wall of a CC with partially ciliated cells and numerous siderophages in the cyst wall. (c) RCC with numerous ciliated cells. Note adjacent adenohypophysis ( lower half ). Insets show colloidal cyst contents (a, b) and focal squamous metaplasia (c) . Original magnification ×200, insets ×400. Hematoxylin and eosin staining; insets in (a) and (b) show periodic acid-Schiff staining. (Color version of figure is available online).

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Discussion

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Academic Radiology, Volume 20, Issue 11
Journals General Radiology
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