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Pediatrics

Pediatric Sellar Region: Work It as a System

Fellowship-level neuroradiology teaching by E. Brooke Schrickel, MD. Open this topic in the interactive reading room →

Watch · concise explainerVisual summary

Core clinical idea

Work the pediatric sella as a system: find the posterior bright spot and place it (intrasellar vs ectopic high along the median eminence vs absent), judge the stalk, then triage any midline mass by signal (fat vs cyst vs solid), enhancement (hamartoma and most cysts don't enhance; craniopharyngioma and tumors do), and the midline company it keeps.

Bottom line

Find the bright spot, follow the stalk, then triage the midline mass by fat/cyst/solid and enhancement.

Core workstation questions

  • Is the posterior bright spot intrasellar, ectopic (high, along the median eminence), or truly absent — and where is the stalk?
  • Is this midline lesion fat, cyst, or solid — and does it enhance?
  • Does a tuber cinereum mass enhance? Enhancement argues against hamartoma.
  • Could a nasal/sphenoid 'mass' be herniated brain (basal encephalocele) before anyone biopsies it?
  • Have I checked the chiasm, optic nerves, septum pellucidum, and corpus callosum for the midline-anomaly cluster?

What changes reporting / management

  • Report an ectopic posterior bright spot explicitly (location along median eminence, attenuated/absent stalk) and trigger a midline anomaly sweep; it travels with GH deficiency and septo-optic dysplasia / holoprosencephaly.
  • Call a nasopharyngeal/sphenoid mass an encephalocele when brain/third ventricle/optic apparatus has herniated — the value is preventing a transnasal biopsy of brain.
  • A mixed cystic-solid, calcified, enhancing suprasellar mass in a child should be reported as craniopharyngioma until proven otherwise.
  • Describe a tuber cinereum mass as non-enhancing and isointense to gray matter (favoring hamartoma); flag enhancement as a reason to consider germ cell tumor or histiocytosis instead.
  • Recognize a persistent craniopharyngeal canal / ectopic gland so it is not mistaken for an aggressive lesion or surgically violated.

Practical traps

  • Calling a normally bright, plump neonatal anterior pituitary 'abnormal' before it settles to adult appearance by ~2-3 months.
  • Declaring the posterior bright spot absent without looking up the stalk and median eminence for an ectopic lobe.
  • Reading a tiny pituitary as an incidental note in a child worked up for short stature or visual loss instead of as part of the gland-stalk-chiasm-septum package.
  • Mistaking a non-enhancing tuber cinereum hamartoma for, or overlooking that an enhancing one could be, a germ cell tumor or Langerhans cell histiocytosis.
  • Treating a basal/transsphenoidal encephalocele as a nasal soft-tissue mass and biopsying herniated brain.

Teaching pearls

  • Absent intrasellar bright spot? Look up the stalk before you call it gone.
  • Mixed cystic-solid, calcified, enhancing suprasellar mass in a kid = craniopharyngioma.
  • A tuber cinereum mass that enhances is not a hamartoma.
  • Nasal mass in a baby with feeding trouble — prove it isn't an encephalocele before anyone biopsies it.
  • One midline anomaly invites a midline search; don't stop at the gland.

Teaching visuals

Sellar region — epicenter first, then the differentialCoronal · where the lesion is centered drives what it is2314LOCATE, THEN DIFFERENTIATEepicenter vs the sella1Intrasellaradenoma · Rathke cleft cyst ·hypophysitis2Suprasellarcraniopharyngioma · meningioma ·aneurysm · glioma3Infundibular / stalkLCH · germinoma · sarcoid ·hypophysitis · mets4Parasellar (cavernous)meningioma · schwannoma · ICAaneurysm · perineuralThe clinical hingeDon't reach for a diagnosis until you've fixed the EPICENTER relative to the sella: inside it, above it, on the stalk,or lateral in the cavernous sinus. Each compartment has its own short differential — the location does most of thework.Then add the lesion's own features (cystic, calcified, flow void, enhancement) and whether it lifts or invades thechiasm and cavernous sinus.
Sellar & Parasellar Region — Coronal Anatomy & Differential by Location

Source lectures

  • Congenital Abnormalities of the Sellar & Parasellar Regions

Educational material for radiology residents and neuroradiology fellows. Nothing here drives individual patient care, and it contains no patient data.