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DOI: 10.1148/rg.274065123
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Lesions of the Hypothalamus: MR Imaging Diagnostic Features1

Sahar N. Saleem, MD, PhD, Ahmed-Hesham M. Said, MD, PhD, and Donald H. Lee, MD

1 From the Department of Diagnostic Radiology, Faculty of Medicine, Cairo University-Kasr Al Ainy Hospital, 4 St 49 Mokattam, Cairo 11451, Egypt (S.N.S.); the Department of Diagnostic Radiology, Faculty of Medicine, Beny-Suif University, Beny-Suif, Egypt (A-H.M.S.); and the Department of Diagnostic Radiology, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada (D.H.L.). Recipient of a Certificate of Merit award for an education exhibit at the 2005 RSNA Annual Meeting. Received June 23, 2006; revision requested September 7 and received October 16; accepted October 18. All authors have no financial relationships to disclose.

Figure 1A
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  		Figure 1a.  (a) Drawing shows the hypothalamus (outlined with a dashed line) lying 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. (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. (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.

 

Figure 1B
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  		Figure 1b.  (a) Drawing shows the hypothalamus (outlined with a dashed line) lying 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. (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. (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.

 

Figure 1C
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  		Figure 1c.  (a) Drawing shows the hypothalamus (outlined with a dashed line) lying 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. (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. (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.

 

Figure 2A
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  		Figure 2a.  Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic chiasm (a), median eminence (b), and mamillary bodies (c) show the various hypothalamic structures. 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.

 

Figure 2B
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  		Figure 2b.  Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic chiasm (a), median eminence (b), and mamillary bodies (c) show the various hypothalamic structures. 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.

 

Figure 2C
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  		Figure 2c.  Coronal T1-weighted MR images obtained at the level of (from rostral to caudal) the optic chiasm (a), median eminence (b), and mamillary bodies (c) show the various hypothalamic structures. 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.

 

Figure 3A
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  		Figure 3a.  Adamantinomatous craniopharyngioma in a 12-year-old boy with headache and blurred vision. Sagittal unenhanced (a) and coronal contrast-enhanced (b) T1-weighted MR images show a lobulated suprasellar tumor with intrasellar extension. The tumor is formed predominantly of multiple cysts with varying signal intensities that show thin mural contrast enhancement (arrows in b). Note the associated asymmetric lateral ventricular dilatation. The diagnosis (adamantinomatous craniopharyngioma) was confirmed at surgery. (Case courtesy of Yasser Ragab, MD, Cairo, Egypt.)

 

Figure 3B
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  		Figure 3b.  Adamantinomatous craniopharyngioma in a 12-year-old boy with headache and blurred vision. Sagittal unenhanced (a) and coronal contrast-enhanced (b) T1-weighted MR images show a lobulated suprasellar tumor with intrasellar extension. The tumor is formed predominantly of multiple cysts with varying signal intensities that show thin mural contrast enhancement (arrows in b). Note the associated asymmetric lateral ventricular dilatation. The diagnosis (adamantinomatous craniopharyngioma) was confirmed at surgery. (Case courtesy of Yasser Ragab, MD, Cairo, Egypt.)

 

Figure 4
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  		Figure 4.  Papillary craniopharyngioma in a 39-year-old man with headache. Sagittal contrast-enhanced T1-weighted MR image shows a predominantly solid, heterogeneously enhancing suprasellar tumor with small, hypointense non-enhancing cystic components (arrows). The diagnosis (papillary craniopharyngioma) was confirmed at surgery.

 

Figure 5
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  		Figure 5.  Metachronous hypothalamic and pineal gland germinomas in a 3-year-old girl with central DI. Sagittal contrast-enhanced T1-weighted MR image shows a well-defined, lobulated, homogeneously enhancing mass (germinoma) involving the proximal part of the infundibular stalk (straight arrow) and the base of the hypothalamus (arrowheads). An associated pineal gland germinoma (curved arrow) is also seen. The diagnosis was confirmed at surgery.

 

Figure 6A
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  		Figure 6a.  Parahypothalamic hamartoma of the tuber cinereum in a 7-year-old boy with precocious puberty. Sagittal (a) and coronal (b) T1-weighted MR images show a well-defined, isointense pedunculated mass (arrow in a) in the characteristic location between the infundibular stalk anteriorly and the mamillary bodies posteriorly. The mass is attached to the floor of the hypothalamus by a narrow base (arrow in b) but does not lie within the substance of the hypothalamus. The diagnosis was confirmed at surgery.

 

Figure 6B
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  		Figure 6b.  Parahypothalamic hamartoma of the tuber cinereum in a 7-year-old boy with precocious puberty. Sagittal (a) and coronal (b) T1-weighted MR images show a well-defined, isointense pedunculated mass (arrow in a) in the characteristic location between the infundibular stalk anteriorly and the mamillary bodies posteriorly. The mass is attached to the floor of the hypothalamus by a narrow base (arrow in b) but does not lie within the substance of the hypothalamus. The diagnosis was confirmed at surgery.

 

Figure 7A
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  		Figure 7a.  Parahypothalamic osteolipoma of the tuber cinereum in a 43-year-old woman with headache and blurred vision. (a) Sagittal T1-weighted MR image shows a well-defined high-signal-intensity lesion at the tuber cinereum (arrow). (b) On an axial fat-suppressed T2-weighted MR image, the lesion exhibits suppressed signal intensity. Arrow indicates a markedly hypointense linear structure that is consistent with bone tissue, a finding that was confirmed at surgery.

 

Figure 7B
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  		Figure 7b.  Parahypothalamic osteolipoma of the tuber cinereum in a 43-year-old woman with headache and blurred vision. (a) Sagittal T1-weighted MR image shows a well-defined high-signal-intensity lesion at the tuber cinereum (arrow). (b) On an axial fat-suppressed T2-weighted MR image, the lesion exhibits suppressed signal intensity. Arrow indicates a markedly hypointense linear structure that is consistent with bone tissue, a finding that was confirmed at surgery.

 

Figure 8A
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  		Figure 8a.  Hypothalamic dermoid cyst in a 30-year-old man with headache. (a) Sagittal T1-weighted MR image shows a well-defined hyperintense lesion (arrow) at the floor of the hypothalamus posterior to the infundibular stalk. (b) On a coronal fat-suppressed T1-weighted MR image, the lesion (arrowheads) exhibits suppressed signal intensity, a finding that indicates adipose contents. The diagnosis (hypothalamic dermoid cyst) was confirmed at surgery.

 

Figure 8B
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  		Figure 8b.  Hypothalamic dermoid cyst in a 30-year-old man with headache. (a) Sagittal T1-weighted MR image shows a well-defined hyperintense lesion (arrow) at the floor of the hypothalamus posterior to the infundibular stalk. (b) On a coronal fat-suppressed T1-weighted MR image, the lesion (arrowheads) exhibits suppressed signal intensity, a finding that indicates adipose contents. The diagnosis (hypothalamic dermoid cyst) was confirmed at surgery.

 

Figure 9A
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  		Figure 9a.  RCC in a 50-year-old woman with diplopia. Coronal T1-weighted (a) and T2-weighted (b) MR images show a well-defined intra- and suprasellar lesion that displaces the optic chiasm upward (arrowheads in a). The cystic contents have high signal intensity on the T1-weighted image and low signal intensity on the T2-weighted image, typical findings that indicate a high concentration of mucopolysaccharides (confirmed at surgery). The epicenter of the lesion is sellar. (Case courtesy of Yasser Ragab, MD, Cairo, Egypt.)

 

Figure 9B
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  		Figure 9b.  RCC in a 50-year-old woman with diplopia. Coronal T1-weighted (a) and T2-weighted (b) MR images show a well-defined intra- and suprasellar lesion that displaces the optic chiasm upward (arrowheads in a). The cystic contents have high signal intensity on the T1-weighted image and low signal intensity on the T2-weighted image, typical findings that indicate a high concentration of mucopolysaccharides (confirmed at surgery). The epicenter of the lesion is sellar. (Case courtesy of Yasser Ragab, MD, Cairo, Egypt.)

 

Figure 10
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  		Figure 10.  Suprasellar colloid cyst in a 44-year-old man with decreased visual acuity. Sagittal T1-weighted MR image shows a well-defined, homogeneously hyperintense suprasellar cyst (curved arrow) that displaces the optic chiasm upward (straight arrow), with intrasellar extension that compresses the pituitary gland (arrowhead). The cyst also showed homogeneous high signal intensity with T2-weighted sequences. The diagnosis (suprasellar colloid cyst) was confirmed at surgery.

 

Figure 11A
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  		Figure 11a.  Hypothalamic-chiasmatic glioma in a 4-year-old boy with NF-1. Sagittal T1-weighted (a) and axial T2-weighted (b) MR images show an irregular hypothalamic mass (arrow in a) that involves the optic chiasm and extends to the right optic nerve (arrowheads in b). The mass has heterogeneous low signal intensity on the T1-weighted image and high signal intensity on the T2-weighted image, findings that are typical for this lesion. The diagnosis (hypothalamic-chiasmatic glioma) was confirmed at surgery.

 

Figure 11B
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  		Figure 11b.  Hypothalamic-chiasmatic glioma in a 4-year-old boy with NF-1. Sagittal T1-weighted (a) and axial T2-weighted (b) MR images show an irregular hypothalamic mass (arrow in a) that involves the optic chiasm and extends to the right optic nerve (arrowheads in b). The mass has heterogeneous low signal intensity on the T1-weighted image and high signal intensity on the T2-weighted image, findings that are typical for this lesion. The diagnosis (hypothalamic-chiasmatic glioma) was confirmed at surgery.

 

Figure 12A
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  		Figure 12a.  Hypothalamic ganglioglioma in a 20-year-old man with headache and blurred vision. Coronal contrast-enhanced T1-weighted (a) and T2-weighted (b) MR images and sagittal contrast-enhanced T1-weighted image (c) show an irregular hypothalamic mass with mixed cystic and enhancing solid components (arrow in c). The cystic components are hyperintense relative to CSF (arrow in a and b).

 

Figure 12B
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  		Figure 12b.  Hypothalamic ganglioglioma in a 20-year-old man with headache and blurred vision. Coronal contrast-enhanced T1-weighted (a) and T2-weighted (b) MR images and sagittal contrast-enhanced T1-weighted image (c) show an irregular hypothalamic mass with mixed cystic and enhancing solid components (arrow in c). The cystic components are hyperintense relative to CSF (arrow in a and b).

 

Figure 12C
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  		Figure 12c.  Hypothalamic ganglioglioma in a 20-year-old man with headache and blurred vision. Coronal contrast-enhanced T1-weighted (a) and T2-weighted (b) MR images and sagittal contrast-enhanced T1-weighted image (c) show an irregular hypothalamic mass with mixed cystic and enhancing solid components (arrow in c). The cystic components are hyperintense relative to CSF (arrow in a and b).

 

Figure 13A
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  		Figure 13a.  Choristoma in a 55-year-old man with gradual diminution of vision. Coronal unenhanced (a) and sagittal contrast-enhanced (b) T1-weighted MR images show a well-defined suprasellar mass (arrow). The mass is iso- to slightly hypointense relative to the brain on the unenhanced image and shows inhomogeneous enhancement on the contrast-enhanced image.

 

Figure 13B
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  		Figure 13b.  Choristoma in a 55-year-old man with gradual diminution of vision. Coronal unenhanced (a) and sagittal contrast-enhanced (b) T1-weighted MR images show a well-defined suprasellar mass (arrow). The mass is iso- to slightly hypointense relative to the brain on the unenhanced image and shows inhomogeneous enhancement on the contrast-enhanced image.

 

Figure 14A
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  		Figure 14a.  Hypothalamic hemangioblastoma in a 54-year-old woman with headache. (a) Sagittal T1-weighted MR image shows a heterogeneous, hypointense hypothalamic lesion (arrowhead). (b) On a coronal contrast-enhanced T1-weighted MR image, the lesion demonstrates complex cystic components with marginal contrast enhancement (short arrow) and an intensely enhancing mural nodule (long arrow).

 

Figure 14B
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  		Figure 14b.  Hypothalamic hemangioblastoma in a 54-year-old woman with headache. (a) Sagittal T1-weighted MR image shows a heterogeneous, hypointense hypothalamic lesion (arrowhead). (b) On a coronal contrast-enhanced T1-weighted MR image, the lesion demonstrates complex cystic components with marginal contrast enhancement (short arrow) and an intensely enhancing mural nodule (long arrow).

 

Figure 15A
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  		Figure 15a.  Hypothalamic cavernoma in a 9-year-old boy with acute diminution of vision (chiasmatic apoplexy). (a) Sagittal T1-weighted MR image shows a hypothalamic lesion with central hyperintensity (arrow), a finding that indicates hemorrhage. (b) Axial T2-weighted MR image shows a signal void (arrowhead) that represents a vascular structure. (c) On a coronal contrast-enhanced T1-weighted MR image, the major vein within the lesion (arrowhead) is markedly enhanced and has a typical aberrant transparenchymal course. The MR imaging finding of blood of different ages in a hypothalamic lesion is highly suggestive of cavernoma.

 

Figure 15B
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  		Figure 15b.  Hypothalamic cavernoma in a 9-year-old boy with acute diminution of vision (chiasmatic apoplexy). (a) Sagittal T1-weighted MR image shows a hypothalamic lesion with central hyperintensity (arrow), a finding that indicates hemorrhage. (b) Axial T2-weighted MR image shows a signal void (arrowhead) that represents a vascular structure. (c) On a coronal contrast-enhanced T1-weighted MR image, the major vein within the lesion (arrowhead) is markedly enhanced and has a typical aberrant transparenchymal course. The MR imaging finding of blood of different ages in a hypothalamic lesion is highly suggestive of cavernoma.

 

Figure 15C
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  		Figure 15c.  Hypothalamic cavernoma in a 9-year-old boy with acute diminution of vision (chiasmatic apoplexy). (a) Sagittal T1-weighted MR image shows a hypothalamic lesion with central hyperintensity (arrow), a finding that indicates hemorrhage. (b) Axial T2-weighted MR image shows a signal void (arrowhead) that represents a vascular structure. (c) On a coronal contrast-enhanced T1-weighted MR image, the major vein within the lesion (arrowhead) is markedly enhanced and has a typical aberrant transparenchymal course. The MR imaging finding of blood of different ages in a hypothalamic lesion is highly suggestive of cavernoma.

 

Figure 16A
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  		Figure 16a.  Metastatic carcinoma to the hypothalamic-pituitary axis in a 46-year-old woman with breast cancer. (a) Sagittal T1-weighted MR image shows a large clival mass with destruction of the sella and invasion of the suprasellar region (arrow). (b) Corresponding contrast-enhanced MR image clearly shows extension of the metastatic lesion and depicts a small enhancing hypothalamic mass (arrow).

 

Figure 16B
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  		Figure 16b.  Metastatic carcinoma to the hypothalamic-pituitary axis in a 46-year-old woman with breast cancer. (a) Sagittal T1-weighted MR image shows a large clival mass with destruction of the sella and invasion of the suprasellar region (arrow). (b) Corresponding contrast-enhanced MR image clearly shows extension of the metastatic lesion and depicts a small enhancing hypothalamic mass (arrow).

 

Figure 17
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  		Figure 17.  Hypothalamic encephalitis in a 35-year-old man with DI. Coronal T2-weighted MR image reveals a hyperintense area in the thalam-ic-hypothalamic region (arrow) that corresponds to edematous changes. (Courtesy of Yasser Ragab, MD, Cairo, Egypt.)

 

Figure 18
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  		Figure 18.  LCH in an 8-year-old boy with DI. Sagittal contrast-enhanced T1-weighted MR image shows a thickened infundibular stalk (arrow). Note that the normal hyperintensity of the posterior pituitary gland is missing. (Courtesy of Yasser Ragab, MD, Cairo, Egypt.)

 

Figure 19A
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  		Figure 19a.  Neurosarcoidosis in a 32-year-old woman with DI. (a) Coronal unenhanced T1-weighted MR image shows irregular thickening of the optic chiasm (arrow). (b) Corresponding contrast-enhanced MR image shows widespread nodular leptomeningeal and infundibular stalk enhancement (arrows). Note that the leptomeningeal granulomas are not visible on the unenhanced image.

 

Figure 19B
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  		Figure 19b.  Neurosarcoidosis in a 32-year-old woman with DI. (a) Coronal unenhanced T1-weighted MR image shows irregular thickening of the optic chiasm (arrow). (b) Corresponding contrast-enhanced MR image shows widespread nodular leptomeningeal and infundibular stalk enhancement (arrows). Note that the leptomeningeal granulomas are not visible on the unenhanced image.

 

Figure 20
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  		Figure 20.  Hemorrhagic pituitary adenoma with a fluid-fluid level in a 42-year-old woman with headache and visual field defects. Sagittal contrast-enhanced T1-weighted MR image shows a large, enhancing, solid sellar and suprasellar tumor. Arrows indicate a fluid-debris level created by the sedimentation of long-standing hemorrhage within the tumor. The diagnosis (hemorrhagic pituitary adenoma) was confirmed at surgery.

 

Figure 21
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  		Figure 21.  EPP in an 8-year-old boy with growth retardation. Sagittal T1-weighted MR image shows the posterior pituitary gland in an abnormal location at the median eminence and appearing as a small, well-defined area of hyperintensity (arrow). Note that the anterior pituitary gland is small and the infundibular stalk is not visible. (Courtesy of Yasser Ragab, MD, Cairo, Egypt.)

 




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