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Dr Ahmed Esawy
‫الرحيم‬‫الرحمن‬‫اهلل‬‫بسم‬
Dr Ahmed Esawy
Dr. Ahmed Abdallah Eisawy
MBBS M.Sc MD
Dr Ahmed Esawy
HYPOTHALAMUS
MRI
IMAGING
Dr Ahmed Esawy
the hypothalamus is a portion of the brain that
contains a number of small nuclei with a variety of
functions.
One of the most important functions of the
hypothalamus is to link the nervous system to
the endocrine system via the pituitary
gland (hypophysis).
The hypothalamus is located below the thalamus, just
above the brainstem and is part of the limbic system
Dr Ahmed Esawy
The hypothalamus is involved in the following
control systems:
• body temperature
• autonomic nervous system
• emotional and food behavior
• endocrine (via the pituitary)
• circadian rhythm.
Dr Ahmed Esawy
The hypothalamus is a portion of the brain near the third
ventricle, located below the thalamus and above the
brainstem.
The anterior boundary of the hypothalamus is determined by
the line connecting, the lamina terminalis and the optic chiasm
at its lower border and the anterior commissure above .
The lower limit of the hypothalamus is formed by the
infundibulum, the tuber cinerum and the mamillary bodies
(from front to back ).
superior: an imaginary line drawn between the anterior and
posterior commissures
The posterior limit is represented by a straight line joining the
mamillary bodies and the posterior commissure.
Dr Ahmed Esawy
(a) Drawing shows the hypothalamus (outlined with a dashed line) below an imaginary
line between the anterior commissure (AC) and the posterior commissure (PC).
The anterior boundary of the hypothalamus is the lamina terminalis (LT), which extends
between the optic chiasm (OC) and the anterior commissure.
The posterior boundary is imprecise; it is indicated by a line that extends between the
mamillary bodies (MB) and the posterior commissure.
The floor of the hypothalamus is formed by the infundibular stalk (IS), the tuber cinereum
(TC), and the mamillary bodies.
The major tracts related to the hypothalamus, the mamillothalamic tract (MT) and the
postcommissural fornix (PF), are also shown.
Dr Ahmed Esawy
(c) On a sagittal contrast material–enhanced MR image,the infundibular stalk and
pituitary gland show normal homogeneous enhancement, which reflects their lack of a
blood-brain barrier
Dr Ahmed Esawy
Dr Ahmed Esawy
(b) Sagittal T1-weighted MR image clearly demonstrates the anatomy of the
hypothalamus. Note the high-signal-intensity area (arrowhead) representing the
posterior pituitary gland.
AC anterior commissure, IS infundibular stalk, LT lamina terminalis, MB mamillary
bodies, OC optic chiasm, PC posterior commissure, TC tuber cinereum.
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted sagittal cut. .
1, Anterior commissure.
2, Corpus callosum.
3, Third ventricle.
4, Cerebellum.
5, Pons.
6, Pituitary gland.
Dr Ahmed Esawy
(a) median eminence (b), mamillary bodies
The major hypothalamic tracts and nuclei (circled) are arranged symmetrically about the
floor and lower medial surface of the third ventricle and include the arcuate nucleus
A), anterior commissure(AC), dorsomedial nucleus (DM), lateral nucleus (L),
lateral preoptic nucleus(LPO), mamillary bodies(MB), medial preoptic nucleus(MPO)
posterior nucleus (P), paraventricular nucleus (PV), suprachiasmatic nucleus (SC),
supraoptic nucleus (SO), and ventromedial nucleus (VM).
The arcuate nucleus is located at the base of the infundibulum. F fornix, ME median
eminence, MT mamillothalamic tract, OC optic chiasm, OT optic tract
Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the
optic chiasm
Dr Ahmed Esawy
Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic
chiasm
(c) show the various hypothalamic structures
lateral nucleus (L), F fornix, mamillary bodies(MB), MT mamillothalamic
, posterior nucleus (P), paraventricular nucleus (PV)
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted axial cut. .
1, Anterior commissure.
2, Putamen.
3, Third ventricle.
4, Corpus callosum.
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted coronal cut. .
1, Anterior commissure.
2, Caudate nucleus.
3, Corpus callosum.
4, Lateral ventricle.
5, Third ventricle.
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted axial cut. .
1, Infudibulum.
2, Cerebral aqueduct.
3, Midbrain.
4, Substantia nigra.
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted coronal cut. Image .
1, Infudibulum.
2, Caudate nucleus.
3, Corpus callosum.
4, Lateral ventricle.
5, Pituitary gland.
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted sagittal cut. Image .
1, Mammillary body.
2, Corpus callosum.
3, Third ventricle.
4, Cerebellum.
5, Midbrain.
6, Pons.
7, Pituitary gland.
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted axial cut. Image .
1, Mammillary body.
2, Cerebral aqueduct.
3, Superior colliculus.
Dr Ahmed Esawy
MRI of the Brain (hypothalamus):
T1-weighted sagittal cut.
1, Posterior commissure.
2, Midbrain.
3, Pituitary gland.
4, Récessus optique.
5, Corpus callosum.
Dr Ahmed Esawy
mammillary bodies
• are a pair of small round bodies, located on the
undersurface of the brain, that form part of the
limbic system.
• They are located at the ends of the anterior
arches of the fornix,
• named mammillary for their resemblance to
two breasts.
• They consist of two groups of nuclei, the
medial mammillary nuclei and the lateral
mammillary nuclei.
• Neuroanatomists have often categorized the
mammillary bodies as part of the hypothalamus
Dr Ahmed Esawy
tuber cinereum
• is a hollow eminence of gray matter situated
between the mammilary bodies behind, and
the optic chiasma in front.
• The tuber cinereum is part of the hypothalamus
• A prominence of the base of the hypothalamus,
extending ventrally into the infundibulum and
pituitary stalk
• tuber cinereum Layer of gray matter in the
hypothalamus that also forms part of the floor
of the third ventricle.
Dr Ahmed Esawy
(a) Drawing shows the hypothalamus (outlined with a dashed line) below an imaginary
line between the anterior commissure (AC) and the posterior commissure (PC).
The anterior boundary of the hypothalamus is the lamina terminalis (LT), which extends
between the optic chiasm (OC) and the anterior commissure.
The posterior boundary is imprecise; it is indicated by a line that extends between the
mamillary bodies (MB) and the posterior commissure.
The floor of the hypothalamus is formed by the infundibular stalk (IS), the tuber cinereum
(TC), and the mamillary bodies.
The major tracts related to the hypothalamus, the mamillothalamic tract (MT) and the
postcommissural fornix (PF), are also shown.
Dr Ahmed Esawy
Locations of Hypothalamic Nuclei with
Respect to the Medial-Lateral and
Rostral-Caudal Axes
.
Lateral AreaMedial AreaRegion*
Lateral preoptic nucleus,
lateral nucleus,
part of supraoptic
nucleus
Medial preoptic nucleus,
supraoptic nucleus,
paraventricular nucleus,
anterior nucleus,
suprachiasmatic nucleus
Anterior
Lateral nucleus, lateral
tuberal nuclei
Dorsomedial nucleus,
ventromedial nucleus,
arcuate nucleus
Tuberal
Lateral nucleusMamillary nuclei,
posterior nucleus
Posterio
*The rostral-caudal axis divides the hypothalamus into anterior, tuberal, and
posterior regions.
Dr Ahmed Esawy
Classification of Hypothalamic Lesions
• Developmental abnormalities
Craniopharyngioma, germinoma,hamartoma, lipoma , dermoid and
epidermoid cysts, arachnoid cyst, RCC, colloid cyst
• Primary tumors of the CNS
Hypothalamic-chiasmatic glioma, ganglioglioma, choristoma, perisellar
meningioma
• Vascular tumors
Hemangioblastoma, cavernoma
• Systemic tumors affecting the CNS
Metastasis, lymphoma, leukemia
• Inflammatory and granulomatous diseases
LCH, lymphocytic infundibuloneurohypophysitis, sarcoidosis, Wegener
granulomatosis, tuberculosis, syphilis, encephalitis
• Lesions arising from surrounding structures
Suprasellar pituitary tumor, ectopic posterior pituitary (EPP), aneurysms
Dr Ahmed Esawy
Classification of Hypothalamic Lesions
LesionsPathologic Process
Craniopharyngioma, germinoma,
hamartoma, lipoma, dermoid and
epidermoid cysts, arachnoid cyst, RCC,
colloid cyst
Developmental abnormalities
Hypothalamic-chiasmatic glioma,
ganglioglioma, choristoma, perisellar
meningioma
Primary tumors of the CNS
Hemangioblastoma, cavernomaVascular tumors
Metastasis, lymphoma, leukemiaSystemic tumors affecting the
CNS
LCH, lymphocytic
infundibuloneurohypophysitis,
sarcoidosis, Wegener
granulomatosis, tuberculosis, syphilis,
encephalitis
Inflammatory and granulomatous
diseases
Suprasellar pituitary tumor, ectopic
posterior pituitary (EPP), aneurysms
Lesions arising from surrounding
structures
Dr Ahmed Esawy
Characteristic Anatomic Locations and Key MR
Imaging Features of Hypothalamic Lesions
Key MR Imaging FeaturesLocationLesion
Solid and cystic components (solid:
heterogeneous enhancement; cystic:
variable signal intensity [T1 hyperintensity]),
calcification
Along suprasellar
portion of
stalk
Craniopharyngioma
Solid; iso- to hypointense with T1-weighted
sequences, iso- to hyperintense with T2-
weighted sequences relative to gray matter;
contrast enhancement; may be associated
with pineal infiltration
Upper part of
infundibulum
Germinoma
Solid, sometimes with cysts; isointense with
T1-weighted sequences, iso- to
hyperintense with T2-weighted sequences
relative to gray matter;
no contrast enhancement or calcification
Tuber cinereumHamartoma
Dr Ahmed Esawy
Characteristic Anatomic Locations and Key MR
Imaging Features of Hypothalamic Lesions
Key MR Imaging FeaturesLocationLesion
Heterogeneous signal intensity similar to
that of fat
Tuber cinereumOsteolipoma
Lobulated borders, isointense with T1-
and T2-weighted sequences relative to
CSF, hyperintense with FLAIR and
diffusion-weighted sequences, no
contrast enhancement
ParasellarEpidermoid cyst
Solid, inhomogeneous signal intensity
similar to that of fat
Suprasellar,
hypothalamic
(midline)
Dermoid cyst
Isointense relative to CSF, no contrast
enhancement
SuprasellarArachnoid cyst
Dr Ahmed Esawy
Characteristic Anatomic Locations and Key MR
Imaging Features of Hypothalamic Lesions
Key MR Imaging FeaturesLocationLesion
Smooth walls with variable signal
intensity, no solid component or
calcification
Supra- or intrasellarRCC
Solid; hypointense with T1-weighted
sequences,hyperintense with T2-
weighted sequences;
moderately heterogeneous contrast
enhancement
Hypothalamic-chiasmicGlioma
Isointense with T1- and T2-weighted
sequences,
variable contrast enhancement
InfundibulumChoristoma
Isointense with T1- and T2-weighted
sequences,
intense homogeneous contrast
enhancement,
dural tail
Suprasellar (rarely in stalk)Meningioma
Dr Ahmed Esawy
Characteristic Anatomic Locations and Key MR
Imaging Features of Hypothalamic Lesions
Key MR Imaging FeaturesLocationLesion
Cyst with enhancing mural noduleHypothalamusHemangioblastoma
Intense contrast enhancement,
bone destruction
without marked sellar enlargement
Stalk, hypothalamusMetastatic disease
Intense contrast enhancement,
associated intraand
extracranial lesions
StalkLCH
Leptomeningeal contrast
enhancement, associated
intra- and extracranial lesions
Stalk, suprasellar cisternSarcoidosis
Isointense relative to brain, strong
enhancement,
may contain cystic component or
hemorrhage;
sellar enlargement
Intrasellar center causing
upward displacement of
optic chiasm
Suprasellar pituitary
adenoma
Blood products, residual patent
lumen, phase
artifact
SuprasellarSuprasellar
aneurysm
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Adamantinomatous craniopharyngioma in a 12-year-old boy
Dr Ahmed Esawy
a Girl, 6-year-old, short stature, reduction of the visual field:
craniopharyngioma with predominant cystic component, thin wall calcifications seen on
CT, spontaneous hypersignal on T1 weighted images in relation with high cholesterol
concentration within the cyst.
Dr Ahmed Esawy
boy, 5-year-old: short stature, headache and vomiting; craniopharyngioma
with hydrocephalus, ‘‘egg-shell’’ calcification on CT,spontaneous T1 hyperintense
cystic part on MRI
Dr Ahmed Esawy
Girl 9-year old, visual disturbance since several months, papillary edema on
fundoscopy:craniopharyngioma with predominantly cystic component,peripheral rim
enhancement after contrast injection.
Dr Ahmed Esawy
Boy, 4-year-old, vomits since 2 weeks, palsy of the right 6th nerve:
craniopharyngioma with T1 isointense cystic component,
intra sellar solid component.
localized MR spectroscopy within the cyst demonstrates a doublet
lactate peak
Dr Ahmed Esawy
Papillary craniopharyngioma in a 39-year-old man
Dr Ahmed Esawy
unenhanced and enhanced T1 craniopharyngioma
large intrasellar and suprasellar mass with cystic and enhancing components as well
as calcifications
DD : dermiod
Dr Ahmed Esawy
craniopharyngioma
Dr Ahmed Esawy
Metachronous hypothalamic and pineal gland germinomas in a 3-year-old girl
T1+C
Dr Ahmed Esawy
Girl, 11-year-old with
diabetes insipidus:
suprasellar germinoma
with cysts
Dr Ahmed Esawy
Boy, 14-year-old,
diabetes insipidus since
6 months: intra and
suprasellar germinoma
with heterogeneous solid
mass.
Dr Ahmed Esawy
Boy, 11-year-old, oculomotor palsy: suprasellar malignant
germinoma with heterogeneous enhancement
Dr Ahmed Esawy
Girl, 9-year-old,
headaches and visual disturbances: Synchronous lesions in pineal and suprasellar
regions
germinoma
Dr Ahmed Esawy
The mass enhances after gadolinium.
Continue with next images
T2
Dr Ahmed Esawy
MRI OF Hypothalamic hamartoma
T1: isointense to cerebral cortex
T1 C+ (Gd): no contrast enhancement
T2
iso- to hyperintense to cerebral cortex
the higher the proportion of glial cells, the higher the T2 signal
MR spectroscopy
reduced NAA/Cr
increased myoinositol
increased Cho/Cr compared to the amygdala has also been reported
Dr Ahmed Esawy
Parahypothalamic hamartoma of the tuber cinereum in a 7-year-old boy
T1+NO C
Dr Ahmed Esawy
Hypothalamic hamartoma
T2
Dr Ahmed Esawy
Hypothalamic hamartoma
T1+C
Dr Ahmed Esawy
T2
T1
FLAIR
T1+C
Hypothalamic hamartoma
Dr Ahmed Esawy
hamartomas on are enhanced sagittal T1-weighted MR images.
Here you can see the non-enhancing hamartoma attached to the tuber cinereum
between the pituitary stalk and mamillary body. There really is no differential diagnosis
Dr Ahmed Esawy
Parahypothalamic osteolipoma of the tuber cinereum in a 43-year-old woman
T1+NO C
FAT SUPRESSED T2
Dr Ahmed Esawy
Girl, 8-year-old, headaches and left visual impairement: suprasellar and pre
pontine epidermoid cyst
Dr Ahmed Esawy
Hypothalamic dermoid cyst in a 30-year-old man
FAT SUPRESSED T1T1+NO C
Dr Ahmed Esawy
RCC in a 50-year-old woman
T1+NO C
T2
Dr Ahmed Esawy
Girl, 1-year-old, MRI performed for psychomotor development delay: incidental
Rathke’s cleft cyst
Dr Ahmed Esawy
T1, T2 and T1-weighted images after gadolinium demonstrate another Rathke's cleft
cyst located in the pituitary gland
Dr Ahmed Esawy
• Suprasellar colloid cyst in a 44-year-old
T1+NO C
Dr Ahmed Esawy
a Boy, one-year-old, mildline defect with frontonasal encephalocele,
suprasellar arachnoid cyst, hypophysis hypoplasia
Dr Ahmed Esawy
Boy, 11-year-old, MRI for advanced puberty: incidental lipoma demonstrated, with
spontaneous T1 hypersignal posterior to the pituitary stalk
Dr Ahmed Esawy
Magnetic resonance images of the
hypothalamus
obtained (a) Axial spin-echo T2-weighted
(b) sagittal T2_Trufisp (c) coronal spin-
echo T2 images
all show well-defined lesions (arrowheads)
with heterogenous signal intensity. Areas of
haemorrhage are seen within the lesion
(mulberry appearance) that are surrounded
by a hypointense hemosiderin rim, which is
in keeping with the diagnosis of
cavernoma.
Cavernoma of the Hypothalamus
Dr Ahmed Esawy
Cavernoma of the Hypothalamus
A sagittal spin-echo T1-weighted magnetic resonance image obtained revealing the
hypothalamus and suprasellar cistern showing the cavernoma (arrowheads) causing
a mass effect and displacing the optic chiasm anteriorly and superiorly (white arrow).
Dr Ahmed Esawy
Hypothalamic-chiasmatic glioma in a 4-year-old boy
T1+NO C T2
Dr Ahmed Esawy
Hypothalamic and Chiasm Glioma
Dr Ahmed Esawy
Optic hypothalamic
astrocytoma 16 year child
Dr Ahmed Esawy
Pediatric Chiasmatic/ Hypothalamic
Gliomas
MRI –T1: Low -intensity with marked
gadolinium enhancement – T2:
Hyperintense mass
Dr Ahmed Esawy
MRI –T1: Low -intensity with marked
gadolinium enhancement enhancement –
T2: Hyperintense mass
Pediatric Chiasmatic Hypothalamic
Gliomas
Dr Ahmed Esawy
Hypothalamic ganglioglioma in a 20-year-old man
T1+NO C T1+ C
T2
Dr Ahmed Esawy
T1+C T2
T1+ NO C FLAIR
Hypothalamic LIPOMA
Dr Ahmed Esawy
Choristoma in a 55-year-old man
T1+NO C
T1+ C
Dr Ahmed Esawy
Hypothalamic hemangioblastoma in a 54-year-old woman
T1+NO C T1+C
Dr Ahmed Esawy
Hypothalamic cavernoma in a 9-year old boy
T1+NO C T2
Dr Ahmed Esawy
Hypothalamic cavernoma in a 9-year old boy
T1+ C
Dr Ahmed Esawy
Metastatic carcinoma to the hypothalamic-pituitary axis in a 46-year-old woman
with breast cancer
T1
T1+C T1+ C
Dr Ahmed Esawy
Hypothalamic encephalitis in a 35-year-old man with DI
T2
Dr Ahmed Esawy
LCH in an 8-year-old boy with DI
T1+C
Dr Ahmed Esawy
Boy, 4-year-old, diabetes insipidus: Langerhans cell hystiocytosis
with enlarged pituitary stalk, occipital osteolysis
Dr Ahmed Esawy
MRI reveals normal and abnormal hypothalamic-pituitary regions. In two healthy
controls, a hot signal in the pituitary lobe that is clearly separated from the dorsum
sella can be observed (A,B: T1-weighted).
A patient with LCH shows a thickened stalk and the loss of the hot spot in the
posterior lobe (C: T1-weighted).
Dr Ahmed Esawy
Gadolinium-enhanced MRIs show a hypothalamic mass in two patients with LCH (A,
B), each of which was histopathologically confirmed to be LCH by biopsy
Dr Ahmed Esawy
MRI of patients with neurodegenerative disease after treatment for multifocal LCH
show high signals at the basal ganglia (A: Flair, TR=9000) and the cerebellar dentate
nuclear area (B: Flair, TR=9000).
Dr Ahmed Esawy
Neurosarcoidosis in a 32-year-old woman with DI
T1+NO C T1+ C
Dr Ahmed Esawy
Tl-weighted sagittal (a) after Gd-DTPA demonstrates a uniformly hyperintense lesion
with suprasellar (1) and hypothalamic components (2). (b) Tl-weighted coronal image
after Gd-DTPA demonstrates the cystic suprasellar portion to show marginal
enhancement (arrows); pituitary stalk (arrowheads). Note the relationship
of the lesion to the optic chiasm and the pituitary g1and
Sarcoidosis of the hypothalamus and pituitary stalk
Dr Ahmed Esawy
same patient before
Tl-weighted coranal, unenhanced
image, more posterior, shows the
granulomatous tissue in the
hypothalamus to be of spontaneously
high signal intensity.
Sarcoidosis of the hypothalamus
and pituitary stalk
Dr Ahmed Esawy
same patient before after 4 month Sagittal T1-weighted image demonstrates a
decrease in size of the hyperintense hypothalamic component, while the
presumed cystic suprasellar portion is unchanged
Dr Ahmed Esawy
same patient before after 6 month Sagittal (a) and coronal (b) image after Gd-DTPA
showa lterations in signal intensity and size in both parts of the lesion; the presumed
cystic component being more extensive.
Dr Ahmed Esawy
Hemorrhagic pituitary adenoma with a fluid-fluid level in a 42-year-old woman
T1+ C
Dr Ahmed Esawy
EPP in an 8-year-old boy with growth
retardation.
T1+NO C
Dr Ahmed Esawy
Dr Ahmed Esawy
pituitary macroadenomas are adenomas over 10mm in size
Dr Ahmed Esawy
pituitary macroadenomas are adenomas over 10mm in size
Dr Ahmed Esawy
pituitary macroadenomas
classic 'snowman' configuration caused by constriction by the diaphragma sellae.
Notice the blood-fluid level, indicating hemorrhage.
Dr Ahmed Esawy
pituitary macroadenomas
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
T1-weighted image of a thrombosed aneurysm with high signal intensity on the
unenhanced scan
Dr Ahmed Esawy
partially thrombosed aneurysm in the suprasellar cistern.
The patent lumen is black on these T1-weighted images.
It is surrounded by clot of different ages arranged in layers reaching from the lumen
to the wall. It resembles an onion cut in half
Dr Ahmed Esawy
Dr Ahmed Esawy
Meningiomas are almost always solid lesions, sometimes with a cyst on the edge
Dr Ahmed Esawy
the spread of the lesion along the meninges. The epicentre of the lesion is above
the sella
the main differential diagnosis of
the enhancing mass would include
meningioma, pituitary adenoma and
an aneurysm
Dr Ahmed Esawy
Differential Diagnosis for Lesions
Involving the Hypothalamus
• Some hypothalamic lesions show remarkable
consistency in location, such as hamartoma and
osteolipoma (in the tuber cinereum) .
• A thickened contrast-enhanced infundibulum is the
most typical manifestation of germ cell tumors,
lymphocytic hypophysitis, sarcoidosis,and LCH
• However, idiopathic, isolated infundibular stalk
thickening can be seen in cases of central DI without
evidence of infiltrative processes
Dr Ahmed Esawy
• Lesions of near isointensity relative to the brain include
germinomas,some hamartomas, and suprasellar
meningioma
• This signature MR spectroscopic finding associated
with hypothalamic hamartomas allows differentiation of
these neoplasms from other entities, such as
hypothalamic gliomas and metastatic deposits
Dr Ahmed Esawy
CNS lesions associated with central
precocious puberty
Hypothalamic hamartoma
Craniopharyngioma
Ependymoma
Optic fibromas
Optic glioma
Subarachniod cysts
Hydrocephalus
Cerberal vascular accidents
encephalitis
Dr Ahmed Esawy
Hypothalamic-pituitary gonadal axis
Arcuate nucleus regulate sexual
development Localized found between the
mamillary bodies And infundibulum
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
T1 +C
9 Y old boy ,neurofibromatosis 1 and CPP
Dr Ahmed Esawy
T1 +C
4 Y old boy with CPP
Dr Ahmed Esawy
7y girl
Arachniod cyst with obstructive
hydrocephalus
Dr Ahmed Esawy
7y girl
Hypothalamic pilocystic
astrocytoma
TI+C

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MRI imaging hypothalamus Dr Ahmed Esawy

  • 2. Dr Ahmed Esawy Dr. Ahmed Abdallah Eisawy MBBS M.Sc MD
  • 4. Dr Ahmed Esawy the hypothalamus is a portion of the brain that contains a number of small nuclei with a variety of functions. One of the most important functions of the hypothalamus is to link the nervous system to the endocrine system via the pituitary gland (hypophysis). The hypothalamus is located below the thalamus, just above the brainstem and is part of the limbic system
  • 5. Dr Ahmed Esawy The hypothalamus is involved in the following control systems: • body temperature • autonomic nervous system • emotional and food behavior • endocrine (via the pituitary) • circadian rhythm.
  • 6. Dr Ahmed Esawy The hypothalamus is a portion of the brain near the third ventricle, located below the thalamus and above the brainstem. The anterior boundary of the hypothalamus is determined by the line connecting, the lamina terminalis and the optic chiasm at its lower border and the anterior commissure above . The lower limit of the hypothalamus is formed by the infundibulum, the tuber cinerum and the mamillary bodies (from front to back ). superior: an imaginary line drawn between the anterior and posterior commissures The posterior limit is represented by a straight line joining the mamillary bodies and the posterior commissure.
  • 7. Dr Ahmed Esawy (a) Drawing shows the hypothalamus (outlined with a dashed line) below an imaginary line between the anterior commissure (AC) and the posterior commissure (PC). The anterior boundary of the hypothalamus is the lamina terminalis (LT), which extends between the optic chiasm (OC) and the anterior commissure. The posterior boundary is imprecise; it is indicated by a line that extends between the mamillary bodies (MB) and the posterior commissure. The floor of the hypothalamus is formed by the infundibular stalk (IS), the tuber cinereum (TC), and the mamillary bodies. The major tracts related to the hypothalamus, the mamillothalamic tract (MT) and the postcommissural fornix (PF), are also shown.
  • 8. Dr Ahmed Esawy (c) On a sagittal contrast material–enhanced MR image,the infundibular stalk and pituitary gland show normal homogeneous enhancement, which reflects their lack of a blood-brain barrier
  • 10. Dr Ahmed Esawy (b) Sagittal T1-weighted MR image clearly demonstrates the anatomy of the hypothalamus. Note the high-signal-intensity area (arrowhead) representing the posterior pituitary gland. AC anterior commissure, IS infundibular stalk, LT lamina terminalis, MB mamillary bodies, OC optic chiasm, PC posterior commissure, TC tuber cinereum.
  • 11. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted sagittal cut. . 1, Anterior commissure. 2, Corpus callosum. 3, Third ventricle. 4, Cerebellum. 5, Pons. 6, Pituitary gland.
  • 12. Dr Ahmed Esawy (a) median eminence (b), mamillary bodies The major hypothalamic tracts and nuclei (circled) are arranged symmetrically about the floor and lower medial surface of the third ventricle and include the arcuate nucleus A), anterior commissure(AC), dorsomedial nucleus (DM), lateral nucleus (L), lateral preoptic nucleus(LPO), mamillary bodies(MB), medial preoptic nucleus(MPO) posterior nucleus (P), paraventricular nucleus (PV), suprachiasmatic nucleus (SC), supraoptic nucleus (SO), and ventromedial nucleus (VM). The arcuate nucleus is located at the base of the infundibulum. F fornix, ME median eminence, MT mamillothalamic tract, OC optic chiasm, OT optic tract Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic chiasm
  • 13. Dr Ahmed Esawy Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic chiasm (c) show the various hypothalamic structures lateral nucleus (L), F fornix, mamillary bodies(MB), MT mamillothalamic , posterior nucleus (P), paraventricular nucleus (PV)
  • 14. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted axial cut. . 1, Anterior commissure. 2, Putamen. 3, Third ventricle. 4, Corpus callosum.
  • 15. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted coronal cut. . 1, Anterior commissure. 2, Caudate nucleus. 3, Corpus callosum. 4, Lateral ventricle. 5, Third ventricle.
  • 16. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted axial cut. . 1, Infudibulum. 2, Cerebral aqueduct. 3, Midbrain. 4, Substantia nigra.
  • 17. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted coronal cut. Image . 1, Infudibulum. 2, Caudate nucleus. 3, Corpus callosum. 4, Lateral ventricle. 5, Pituitary gland.
  • 18. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted sagittal cut. Image . 1, Mammillary body. 2, Corpus callosum. 3, Third ventricle. 4, Cerebellum. 5, Midbrain. 6, Pons. 7, Pituitary gland.
  • 19. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted axial cut. Image . 1, Mammillary body. 2, Cerebral aqueduct. 3, Superior colliculus.
  • 20. Dr Ahmed Esawy MRI of the Brain (hypothalamus): T1-weighted sagittal cut. 1, Posterior commissure. 2, Midbrain. 3, Pituitary gland. 4, Récessus optique. 5, Corpus callosum.
  • 21. Dr Ahmed Esawy mammillary bodies • are a pair of small round bodies, located on the undersurface of the brain, that form part of the limbic system. • They are located at the ends of the anterior arches of the fornix, • named mammillary for their resemblance to two breasts. • They consist of two groups of nuclei, the medial mammillary nuclei and the lateral mammillary nuclei. • Neuroanatomists have often categorized the mammillary bodies as part of the hypothalamus
  • 22. Dr Ahmed Esawy tuber cinereum • is a hollow eminence of gray matter situated between the mammilary bodies behind, and the optic chiasma in front. • The tuber cinereum is part of the hypothalamus • A prominence of the base of the hypothalamus, extending ventrally into the infundibulum and pituitary stalk • tuber cinereum Layer of gray matter in the hypothalamus that also forms part of the floor of the third ventricle.
  • 23. Dr Ahmed Esawy (a) Drawing shows the hypothalamus (outlined with a dashed line) below an imaginary line between the anterior commissure (AC) and the posterior commissure (PC). The anterior boundary of the hypothalamus is the lamina terminalis (LT), which extends between the optic chiasm (OC) and the anterior commissure. The posterior boundary is imprecise; it is indicated by a line that extends between the mamillary bodies (MB) and the posterior commissure. The floor of the hypothalamus is formed by the infundibular stalk (IS), the tuber cinereum (TC), and the mamillary bodies. The major tracts related to the hypothalamus, the mamillothalamic tract (MT) and the postcommissural fornix (PF), are also shown.
  • 24. Dr Ahmed Esawy Locations of Hypothalamic Nuclei with Respect to the Medial-Lateral and Rostral-Caudal Axes . Lateral AreaMedial AreaRegion* Lateral preoptic nucleus, lateral nucleus, part of supraoptic nucleus Medial preoptic nucleus, supraoptic nucleus, paraventricular nucleus, anterior nucleus, suprachiasmatic nucleus Anterior Lateral nucleus, lateral tuberal nuclei Dorsomedial nucleus, ventromedial nucleus, arcuate nucleus Tuberal Lateral nucleusMamillary nuclei, posterior nucleus Posterio *The rostral-caudal axis divides the hypothalamus into anterior, tuberal, and posterior regions.
  • 25. Dr Ahmed Esawy Classification of Hypothalamic Lesions • Developmental abnormalities Craniopharyngioma, germinoma,hamartoma, lipoma , dermoid and epidermoid cysts, arachnoid cyst, RCC, colloid cyst • Primary tumors of the CNS Hypothalamic-chiasmatic glioma, ganglioglioma, choristoma, perisellar meningioma • Vascular tumors Hemangioblastoma, cavernoma • Systemic tumors affecting the CNS Metastasis, lymphoma, leukemia • Inflammatory and granulomatous diseases LCH, lymphocytic infundibuloneurohypophysitis, sarcoidosis, Wegener granulomatosis, tuberculosis, syphilis, encephalitis • Lesions arising from surrounding structures Suprasellar pituitary tumor, ectopic posterior pituitary (EPP), aneurysms
  • 26. Dr Ahmed Esawy Classification of Hypothalamic Lesions LesionsPathologic Process Craniopharyngioma, germinoma, hamartoma, lipoma, dermoid and epidermoid cysts, arachnoid cyst, RCC, colloid cyst Developmental abnormalities Hypothalamic-chiasmatic glioma, ganglioglioma, choristoma, perisellar meningioma Primary tumors of the CNS Hemangioblastoma, cavernomaVascular tumors Metastasis, lymphoma, leukemiaSystemic tumors affecting the CNS LCH, lymphocytic infundibuloneurohypophysitis, sarcoidosis, Wegener granulomatosis, tuberculosis, syphilis, encephalitis Inflammatory and granulomatous diseases Suprasellar pituitary tumor, ectopic posterior pituitary (EPP), aneurysms Lesions arising from surrounding structures
  • 27. Dr Ahmed Esawy Characteristic Anatomic Locations and Key MR Imaging Features of Hypothalamic Lesions Key MR Imaging FeaturesLocationLesion Solid and cystic components (solid: heterogeneous enhancement; cystic: variable signal intensity [T1 hyperintensity]), calcification Along suprasellar portion of stalk Craniopharyngioma Solid; iso- to hypointense with T1-weighted sequences, iso- to hyperintense with T2- weighted sequences relative to gray matter; contrast enhancement; may be associated with pineal infiltration Upper part of infundibulum Germinoma Solid, sometimes with cysts; isointense with T1-weighted sequences, iso- to hyperintense with T2-weighted sequences relative to gray matter; no contrast enhancement or calcification Tuber cinereumHamartoma
  • 28. Dr Ahmed Esawy Characteristic Anatomic Locations and Key MR Imaging Features of Hypothalamic Lesions Key MR Imaging FeaturesLocationLesion Heterogeneous signal intensity similar to that of fat Tuber cinereumOsteolipoma Lobulated borders, isointense with T1- and T2-weighted sequences relative to CSF, hyperintense with FLAIR and diffusion-weighted sequences, no contrast enhancement ParasellarEpidermoid cyst Solid, inhomogeneous signal intensity similar to that of fat Suprasellar, hypothalamic (midline) Dermoid cyst Isointense relative to CSF, no contrast enhancement SuprasellarArachnoid cyst
  • 29. Dr Ahmed Esawy Characteristic Anatomic Locations and Key MR Imaging Features of Hypothalamic Lesions Key MR Imaging FeaturesLocationLesion Smooth walls with variable signal intensity, no solid component or calcification Supra- or intrasellarRCC Solid; hypointense with T1-weighted sequences,hyperintense with T2- weighted sequences; moderately heterogeneous contrast enhancement Hypothalamic-chiasmicGlioma Isointense with T1- and T2-weighted sequences, variable contrast enhancement InfundibulumChoristoma Isointense with T1- and T2-weighted sequences, intense homogeneous contrast enhancement, dural tail Suprasellar (rarely in stalk)Meningioma
  • 30. Dr Ahmed Esawy Characteristic Anatomic Locations and Key MR Imaging Features of Hypothalamic Lesions Key MR Imaging FeaturesLocationLesion Cyst with enhancing mural noduleHypothalamusHemangioblastoma Intense contrast enhancement, bone destruction without marked sellar enlargement Stalk, hypothalamusMetastatic disease Intense contrast enhancement, associated intraand extracranial lesions StalkLCH Leptomeningeal contrast enhancement, associated intra- and extracranial lesions Stalk, suprasellar cisternSarcoidosis Isointense relative to brain, strong enhancement, may contain cystic component or hemorrhage; sellar enlargement Intrasellar center causing upward displacement of optic chiasm Suprasellar pituitary adenoma Blood products, residual patent lumen, phase artifact SuprasellarSuprasellar aneurysm
  • 34. Dr Ahmed Esawy Adamantinomatous craniopharyngioma in a 12-year-old boy
  • 35. Dr Ahmed Esawy a Girl, 6-year-old, short stature, reduction of the visual field: craniopharyngioma with predominant cystic component, thin wall calcifications seen on CT, spontaneous hypersignal on T1 weighted images in relation with high cholesterol concentration within the cyst.
  • 36. Dr Ahmed Esawy boy, 5-year-old: short stature, headache and vomiting; craniopharyngioma with hydrocephalus, ‘‘egg-shell’’ calcification on CT,spontaneous T1 hyperintense cystic part on MRI
  • 37. Dr Ahmed Esawy Girl 9-year old, visual disturbance since several months, papillary edema on fundoscopy:craniopharyngioma with predominantly cystic component,peripheral rim enhancement after contrast injection.
  • 38. Dr Ahmed Esawy Boy, 4-year-old, vomits since 2 weeks, palsy of the right 6th nerve: craniopharyngioma with T1 isointense cystic component, intra sellar solid component. localized MR spectroscopy within the cyst demonstrates a doublet lactate peak
  • 39. Dr Ahmed Esawy Papillary craniopharyngioma in a 39-year-old man
  • 40. Dr Ahmed Esawy unenhanced and enhanced T1 craniopharyngioma large intrasellar and suprasellar mass with cystic and enhancing components as well as calcifications DD : dermiod
  • 42. Dr Ahmed Esawy Metachronous hypothalamic and pineal gland germinomas in a 3-year-old girl T1+C
  • 43. Dr Ahmed Esawy Girl, 11-year-old with diabetes insipidus: suprasellar germinoma with cysts
  • 44. Dr Ahmed Esawy Boy, 14-year-old, diabetes insipidus since 6 months: intra and suprasellar germinoma with heterogeneous solid mass.
  • 45. Dr Ahmed Esawy Boy, 11-year-old, oculomotor palsy: suprasellar malignant germinoma with heterogeneous enhancement
  • 46. Dr Ahmed Esawy Girl, 9-year-old, headaches and visual disturbances: Synchronous lesions in pineal and suprasellar regions germinoma
  • 47. Dr Ahmed Esawy The mass enhances after gadolinium. Continue with next images T2
  • 48. Dr Ahmed Esawy MRI OF Hypothalamic hamartoma T1: isointense to cerebral cortex T1 C+ (Gd): no contrast enhancement T2 iso- to hyperintense to cerebral cortex the higher the proportion of glial cells, the higher the T2 signal MR spectroscopy reduced NAA/Cr increased myoinositol increased Cho/Cr compared to the amygdala has also been reported
  • 49. Dr Ahmed Esawy Parahypothalamic hamartoma of the tuber cinereum in a 7-year-old boy T1+NO C
  • 51. Dr Ahmed Esawy Hypothalamic hamartoma T1+C
  • 53. Dr Ahmed Esawy hamartomas on are enhanced sagittal T1-weighted MR images. Here you can see the non-enhancing hamartoma attached to the tuber cinereum between the pituitary stalk and mamillary body. There really is no differential diagnosis
  • 54. Dr Ahmed Esawy Parahypothalamic osteolipoma of the tuber cinereum in a 43-year-old woman T1+NO C FAT SUPRESSED T2
  • 55. Dr Ahmed Esawy Girl, 8-year-old, headaches and left visual impairement: suprasellar and pre pontine epidermoid cyst
  • 56. Dr Ahmed Esawy Hypothalamic dermoid cyst in a 30-year-old man FAT SUPRESSED T1T1+NO C
  • 57. Dr Ahmed Esawy RCC in a 50-year-old woman T1+NO C T2
  • 58. Dr Ahmed Esawy Girl, 1-year-old, MRI performed for psychomotor development delay: incidental Rathke’s cleft cyst
  • 59. Dr Ahmed Esawy T1, T2 and T1-weighted images after gadolinium demonstrate another Rathke's cleft cyst located in the pituitary gland
  • 60. Dr Ahmed Esawy • Suprasellar colloid cyst in a 44-year-old T1+NO C
  • 61. Dr Ahmed Esawy a Boy, one-year-old, mildline defect with frontonasal encephalocele, suprasellar arachnoid cyst, hypophysis hypoplasia
  • 62. Dr Ahmed Esawy Boy, 11-year-old, MRI for advanced puberty: incidental lipoma demonstrated, with spontaneous T1 hypersignal posterior to the pituitary stalk
  • 63. Dr Ahmed Esawy Magnetic resonance images of the hypothalamus obtained (a) Axial spin-echo T2-weighted (b) sagittal T2_Trufisp (c) coronal spin- echo T2 images all show well-defined lesions (arrowheads) with heterogenous signal intensity. Areas of haemorrhage are seen within the lesion (mulberry appearance) that are surrounded by a hypointense hemosiderin rim, which is in keeping with the diagnosis of cavernoma. Cavernoma of the Hypothalamus
  • 64. Dr Ahmed Esawy Cavernoma of the Hypothalamus A sagittal spin-echo T1-weighted magnetic resonance image obtained revealing the hypothalamus and suprasellar cistern showing the cavernoma (arrowheads) causing a mass effect and displacing the optic chiasm anteriorly and superiorly (white arrow).
  • 65. Dr Ahmed Esawy Hypothalamic-chiasmatic glioma in a 4-year-old boy T1+NO C T2
  • 66. Dr Ahmed Esawy Hypothalamic and Chiasm Glioma
  • 67. Dr Ahmed Esawy Optic hypothalamic astrocytoma 16 year child
  • 68. Dr Ahmed Esawy Pediatric Chiasmatic/ Hypothalamic Gliomas MRI –T1: Low -intensity with marked gadolinium enhancement – T2: Hyperintense mass
  • 69. Dr Ahmed Esawy MRI –T1: Low -intensity with marked gadolinium enhancement enhancement – T2: Hyperintense mass Pediatric Chiasmatic Hypothalamic Gliomas
  • 70. Dr Ahmed Esawy Hypothalamic ganglioglioma in a 20-year-old man T1+NO C T1+ C T2
  • 71. Dr Ahmed Esawy T1+C T2 T1+ NO C FLAIR Hypothalamic LIPOMA
  • 72. Dr Ahmed Esawy Choristoma in a 55-year-old man T1+NO C T1+ C
  • 73. Dr Ahmed Esawy Hypothalamic hemangioblastoma in a 54-year-old woman T1+NO C T1+C
  • 74. Dr Ahmed Esawy Hypothalamic cavernoma in a 9-year old boy T1+NO C T2
  • 75. Dr Ahmed Esawy Hypothalamic cavernoma in a 9-year old boy T1+ C
  • 76. Dr Ahmed Esawy Metastatic carcinoma to the hypothalamic-pituitary axis in a 46-year-old woman with breast cancer T1 T1+C T1+ C
  • 77. Dr Ahmed Esawy Hypothalamic encephalitis in a 35-year-old man with DI T2
  • 78. Dr Ahmed Esawy LCH in an 8-year-old boy with DI T1+C
  • 79. Dr Ahmed Esawy Boy, 4-year-old, diabetes insipidus: Langerhans cell hystiocytosis with enlarged pituitary stalk, occipital osteolysis
  • 80. Dr Ahmed Esawy MRI reveals normal and abnormal hypothalamic-pituitary regions. In two healthy controls, a hot signal in the pituitary lobe that is clearly separated from the dorsum sella can be observed (A,B: T1-weighted). A patient with LCH shows a thickened stalk and the loss of the hot spot in the posterior lobe (C: T1-weighted).
  • 81. Dr Ahmed Esawy Gadolinium-enhanced MRIs show a hypothalamic mass in two patients with LCH (A, B), each of which was histopathologically confirmed to be LCH by biopsy
  • 82. Dr Ahmed Esawy MRI of patients with neurodegenerative disease after treatment for multifocal LCH show high signals at the basal ganglia (A: Flair, TR=9000) and the cerebellar dentate nuclear area (B: Flair, TR=9000).
  • 83. Dr Ahmed Esawy Neurosarcoidosis in a 32-year-old woman with DI T1+NO C T1+ C
  • 84. Dr Ahmed Esawy Tl-weighted sagittal (a) after Gd-DTPA demonstrates a uniformly hyperintense lesion with suprasellar (1) and hypothalamic components (2). (b) Tl-weighted coronal image after Gd-DTPA demonstrates the cystic suprasellar portion to show marginal enhancement (arrows); pituitary stalk (arrowheads). Note the relationship of the lesion to the optic chiasm and the pituitary g1and Sarcoidosis of the hypothalamus and pituitary stalk
  • 85. Dr Ahmed Esawy same patient before Tl-weighted coranal, unenhanced image, more posterior, shows the granulomatous tissue in the hypothalamus to be of spontaneously high signal intensity. Sarcoidosis of the hypothalamus and pituitary stalk
  • 86. Dr Ahmed Esawy same patient before after 4 month Sagittal T1-weighted image demonstrates a decrease in size of the hyperintense hypothalamic component, while the presumed cystic suprasellar portion is unchanged
  • 87. Dr Ahmed Esawy same patient before after 6 month Sagittal (a) and coronal (b) image after Gd-DTPA showa lterations in signal intensity and size in both parts of the lesion; the presumed cystic component being more extensive.
  • 88. Dr Ahmed Esawy Hemorrhagic pituitary adenoma with a fluid-fluid level in a 42-year-old woman T1+ C
  • 89. Dr Ahmed Esawy EPP in an 8-year-old boy with growth retardation. T1+NO C
  • 91. Dr Ahmed Esawy pituitary macroadenomas are adenomas over 10mm in size
  • 92. Dr Ahmed Esawy pituitary macroadenomas are adenomas over 10mm in size
  • 93. Dr Ahmed Esawy pituitary macroadenomas classic 'snowman' configuration caused by constriction by the diaphragma sellae. Notice the blood-fluid level, indicating hemorrhage.
  • 94. Dr Ahmed Esawy pituitary macroadenomas
  • 97. Dr Ahmed Esawy T1-weighted image of a thrombosed aneurysm with high signal intensity on the unenhanced scan
  • 98. Dr Ahmed Esawy partially thrombosed aneurysm in the suprasellar cistern. The patent lumen is black on these T1-weighted images. It is surrounded by clot of different ages arranged in layers reaching from the lumen to the wall. It resembles an onion cut in half
  • 100. Dr Ahmed Esawy Meningiomas are almost always solid lesions, sometimes with a cyst on the edge
  • 101. Dr Ahmed Esawy the spread of the lesion along the meninges. The epicentre of the lesion is above the sella the main differential diagnosis of the enhancing mass would include meningioma, pituitary adenoma and an aneurysm
  • 102. Dr Ahmed Esawy Differential Diagnosis for Lesions Involving the Hypothalamus • Some hypothalamic lesions show remarkable consistency in location, such as hamartoma and osteolipoma (in the tuber cinereum) . • A thickened contrast-enhanced infundibulum is the most typical manifestation of germ cell tumors, lymphocytic hypophysitis, sarcoidosis,and LCH • However, idiopathic, isolated infundibular stalk thickening can be seen in cases of central DI without evidence of infiltrative processes
  • 103. Dr Ahmed Esawy • Lesions of near isointensity relative to the brain include germinomas,some hamartomas, and suprasellar meningioma • This signature MR spectroscopic finding associated with hypothalamic hamartomas allows differentiation of these neoplasms from other entities, such as hypothalamic gliomas and metastatic deposits
  • 104. Dr Ahmed Esawy CNS lesions associated with central precocious puberty Hypothalamic hamartoma Craniopharyngioma Ependymoma Optic fibromas Optic glioma Subarachniod cysts Hydrocephalus Cerberal vascular accidents encephalitis
  • 105. Dr Ahmed Esawy Hypothalamic-pituitary gonadal axis Arcuate nucleus regulate sexual development Localized found between the mamillary bodies And infundibulum
  • 110. Dr Ahmed Esawy T1 +C 9 Y old boy ,neurofibromatosis 1 and CPP
  • 111. Dr Ahmed Esawy T1 +C 4 Y old boy with CPP
  • 112. Dr Ahmed Esawy 7y girl Arachniod cyst with obstructive hydrocephalus
  • 113. Dr Ahmed Esawy 7y girl Hypothalamic pilocystic astrocytoma TI+C