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PURPOSE: We investigated the hypothesis that increasing fMRI temporal resolution using a multiband (MB) gradient echo-echo planar imaging (GRE-EPI) pulse sequence provides fMRI language maps of higher statistical quality than those acquired with a traditional GRE-EPI sequence. METHODS: This prospective study enrolled 29 consecutive patients receiving language fMRI prior to a potential brain resection for tumor, AVM, or epilepsy. A 4-min rhyming task was performed at 3.0 Tesla with a traditional GRE-EPI pulse sequence (TR = 2000, TE = 30, matrix = 64/100%, slice = 4/0, FOV = 24, slices = 30, time points = 120) and an additional MB GRE-EPI pulse sequence with an acceleration factor of 6 (TR = 333, TE = 30, matrix 64/100%, slice = 4/0, FOV = 24, time points = 720). Spatially filtered t statistical maps were generated. Volumes of interest (VOIs) were drawn around activations at Broca's, dorsolateral prefrontal cortex, Wernicke's, and the visual word form areas. The t value maxima were measured for the overall brain and each of the VOIs. A paired t test was performed for the corresponding traditional and MB GRE-EPI measurements. RESULTS: The mean age of subjects was 42.6 years old (18-75). Sixty-two percent were male. The average overall brain t statistic maxima for the MB pulse sequence (t = 15.4) was higher than for the traditional pulse sequence (t = 9.3, p = < .0001). This also held true for Broca's area (p < 0.0001), Wernicke's area (p < .0001), dorsolateral prefrontal cortex (p < .0001), and the visual word form area (p < .0001). CONCLUSION: A MB GRE-EPI fMRI pulse sequence employing high temporal resolution provides clinical fMRI language maps of greater statistical significance than those obtained with a traditional GRE-EPI sequence.
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Idioma , Imageamento por Ressonância Magnética , Adulto , Mapeamento Encefálico , Imagem Ecoplanar , Humanos , Masculino , Estudos ProspectivosAssuntos
Biomarcadores/sangue , Biomarcadores/urina , Meios de Contraste/efeitos adversos , Tomografia Computadorizada por Raios X , Administração Intravenosa , Idoso , Biomarcadores/química , Meios de Contraste/administração & dosagem , Feminino , Humanos , Iohexol/efeitos adversos , Iohexol/análogos & derivados , Masculino , Pessoa de Meia-Idade , Projetos PilotoRESUMO
BACKGROUND AND PURPOSE: Feature variability in radiomics studies due to technical and magnet strength parameters is well-known and may be addressed through various preprocessing methods. However, very few studies have evaluated the downstream impact of variable preprocessing on model classification performance in a multiclass setting. We sought to evaluate the impact of Smallest Univalue Segment Assimilating Nucleus (SUSAN) denoising and Combining Batches harmonization on model classification performance. MATERIALS AND METHODS: A total of 493 cases (410 internal and 83 external data sets) of glioblastoma, intracranial metastatic disease, and primary CNS lymphoma underwent semiautomated 3D-segmentation post-baseline image processing (BIP) consisting of resampling, realignment, coregistration, skull-stripping, and image normalization. Post-BIP, 2 sets were generated, one with and another without SUSAN denoising. Radiomics features were extracted from both data sets and batch-corrected to produce 4 data sets: (a) BIP, (b) BIP with SUSAN denoising, (c) BIP with Combining Batches, and (d) BIP with both SUSAN denoising and Combining Batches harmonization. Performance was then summarized for models using a combination of 6 feature-selection techniques and 6 machine learning models across 4 mask-sequence combinations with features derived from 1 to 3 (multiparametric) MRI sequences. RESULTS: Most top-performing models on the external test set used BIP+SUSAN denoising-derived features. Overall, the use of SUSAN denoising and Combining Batches harmonization led to a slight but generally consistent improvement in model performance on the external test set. CONCLUSIONS: The use of image-preprocessing steps such as SUSAN denoising and Combining Batches harmonization may be more useful in a multi-institutional setting to improve model generalizability. Models derived from only T1 contrast-enhanced images showed comparable performance to models derived from multiparametric MRI.
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Historically, MR imaging has been unable to detect a pituitary adenoma in up to one-half of patients with Cushing disease. This issue is problematic because the standard-of-care treatment is surgical resection, and its success is correlated with finding the tumor on imaging. Photon-counting detector CT is a recent advancement that has multiple benefits over conventional energy-integrating detector CT. We present the use of dynamic contrast-enhanced imaging using photon-counting detector CT for the detection of pituitary adenomas in patients with Cushing disease.
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Adenoma , Meios de Contraste , Hipersecreção Hipofisária de ACTH , Neoplasias Hipofisárias , Tomografia Computadorizada por Raios X , Feminino , Humanos , Masculino , Adenoma/diagnóstico por imagem , Fótons , Hipersecreção Hipofisária de ACTH/diagnóstico por imagem , Neoplasias Hipofisárias/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension is an increasingly recognized condition. Spontaneous intracranial hypotension is caused by a CSF leak, which is commonly related to a CSF-venous fistula. In patients with spontaneous intracranial hypotension, multiple intracranial abnormalities can be observed on brain MR imaging, including dural enhancement, "brain sag," and pituitary engorgement. This study seeks to create a deep learning model for the accurate diagnosis of CSF-venous fistulas via brain MR imaging. MATERIALS AND METHODS: A review of patients with clinically suspected spontaneous intracranial hypotension who underwent digital subtraction myelogram imaging preceded by brain MR imaging was performed. The patients were categorized as having a definite CSF-venous fistula, no fistula, or indeterminate findings on a digital subtraction myelogram. The data set was split into 5 folds at the patient level and stratified by label. A 5-fold cross-validation was then used to evaluate the reliability of the model. The predictive value of the model to identify patients with a CSF leak was assessed by using the area under the receiver operating characteristic curve for each validation fold. RESULTS: There were 129 patients were included in this study. The median age was 54 years, and 66 (51.2%) had a CSF-venous fistula. In discriminating between positive and negative cases for CSF-venous fistulas, the classifier demonstrated an average area under the receiver operating characteristic curve of 0.8668 with a standard deviation of 0.0254 across the folds. CONCLUSIONS: This study developed a deep learning model that can predict the presence of a spinal CSF-venous fistula based on brain MR imaging in patients with suspected spontaneous intracranial hypotension. However, further model refinement and external validation are necessary before clinical adoption. This research highlights the substantial potential of deep learning in diagnosing CSF-venous fistulas by using brain MR imaging.
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Anormalidades Múltiplas , Aprendizado Profundo , Fístula , Hipotensão Intracraniana , Humanos , Pessoa de Meia-Idade , Encéfalo/diagnóstico por imagem , Vazamento de Líquido Cefalorraquidiano/diagnóstico por imagem , Vazamento de Líquido Cefalorraquidiano/complicações , Fístula/complicações , Hipotensão Intracraniana/complicações , Hipotensão Intracraniana/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Mielografia/métodos , Reprodutibilidade dos TestesRESUMO
High-grade astrocytoma with piloid features (HGAP) is a recently identified brain tumor characterized by a distinct DNA methylation profile. Predominantly located in the posterior fossa of adults, HGAP is notably prevalent in individuals with neurofibromatosis type 1. We present an image-centric review of HGAP and explore the association between HGAP and neurofibromatosis type 1. Data were collected from 8 HGAP patients treated at two tertiary care institutions between January 2020 and October 2023. Demographic details, clinical records, management, and tumor molecular profiles were analyzed. Tumor characteristics, including location and imaging features on MR imaging, were reviewed. Clinical or imaging features suggestive of neurofibromatosis 1 or the presence of NF1 gene alteration were documented. The mean age at presentation was 45.5 years (male/female = 5:3). Tumors were midline, localized in the posterior fossa (n = 4), diencephalic/thalamic (n = 2), and spinal cord (n = 2). HGAP lesions were T1 hypointense, T2-hyperintense, mostly without diffusion restriction, predominantly peripheral irregular enhancement with central necrosis (n = 3) followed by mixed heterogeneous enhancement (n = 2). Two NF1 mutation carriers showed signs of neurofibromatosis type 1 before HGAP diagnosis, with one diagnosed during HGAP evaluation, strengthening the HGAP-NF1 link, particularly in patients with posterior fossa masses. All tumors were IDH1 wild-type, often with ATRX, CDKN2A/B, and NF1 gene alteration. Six patients underwent surgical resection followed by adjuvant chemoradiation. Six patients were alive, and two died during the last follow-up. Histone H3 mutations were not detected in our cohort, such as the common H3K27M typically seen in diffuse midline gliomas, linked to aggressive clinical behavior and poor prognosis. HGAP lesions may involve the brain or spine and tend to be midline or paramedian in location. Underlying neurofibromatosis type 1 diagnosis or imaging findings are important diagnostic cues.
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Astrocitoma , Neoplasias Encefálicas , Neurofibromatose 1 , Adulto , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Neurofibromatose 1/diagnóstico por imagem , Neurofibromatose 1/patologia , Astrocitoma/diagnóstico por imagem , Astrocitoma/genética , Astrocitoma/patologia , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/patologia , Histonas/genética , Encéfalo/patologia , MutaçãoRESUMO
BACKGROUND AND PURPOSE: Accurately identifying patients with CSF-venous fistulas (CVF), one cause of spontaneous intracranial hypotension (SIH), is a diagnostic dilemma. This conundrum underscores the need for a CVF biomarker to help select who should undergo an invasive myelogram for further diagnostic workup. Beta trace protein (BTP) is the most abundant CNS derived protein in the CSF and therefore is a potential venous biomarker for CVF detection. The purpose of our study was to measure venous BTP levels as a potential CVF biomarker. MATERIALS AND METHODS: We prospectively enrolled 14 patients with CVF and measured BTP in venous blood samples from the paraspinal veins near the CVF and compared those levels to the peripheral blood. Myelograms used initially to identify the CVF were evaluated for modality, CVF laterality, CVF level, and venous drainage pattern. Patient sex, patient age, and symptom duration were also collected. Brain MR images were reviewed for Bern scores. We also measured the peripheral blood BTP levels in 20 normal controls. RESULTS: In patients with CVF, the mean BTP level near the CVF was 54.5% higher (0.760 [SD 0.673] vs 0.492 [SD 0.095] mg/L; p = 0.069) compared to peripheral blood. Nine (64.3%) patients with CVF had a higher paraspinal BTP level than peripheral BTP level. The 20 control patients had a higher the mean peripheral BTP level 0.720 (SD 0.191) mg/L compared to patients with CVF (p<0.001). CONCLUSIONS: We found that venous blood at the site of CVF had higher BTP values compared to peripheral blood in the majority, but not all patients with CVF. This may reflect the intermittent leaking nature of CVF. Additionally, we found that patients with CVF had a lower peripheral blood BTP level compared to normal controls. BTP requires further evaluation as a potential CVF biomarker. ABBREVIATIONS: SIH = Spontaneous Intracranial Hypotension; CVF = CSF-Venous Fistula; CTM = CT myelogram; DSM = Digital Subtraction Myelography; BTP = Beta Trace Protein.
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BACKGROUND AND PURPOSE: CSF leaks of the skull base and spine share a common process of CSF volume loss, and yet only the latter has been associated with spontaneous intracranial hypotension (SIH). Despite published claims that only spinal leaks cause SIH, no prior studies have evaluated brain MR imaging in patients with skull base leaks for findings associated with SIH, such as dural enhancement. The purpose of our study was to use a validated brain MR imaging scoring system to evaluate patients with skull base CSF leaks for findings associated with SIH. MATERIALS AND METHODS: We included patients with confirmed skull base CSF leaks and contrast-enhanced preoperative brain MRI. The preoperative MR images were reviewed for findings associated with SIH by using the Bern score. Patient age, presenting symptoms and their duration, and leak site were also recorded. RESULTS: Thirty-one patients with skull base CSF leaks were included. Mean Bern score was 0.9 (range 0-4, standard deviation 1.1), and only 1 patient (3%) had dural enhancement. Mean age was 53 years (range 18-76). Mean symptom duration was 1.3 years, with 22 patients presenting within 1 year of symptom onset. Twenty-three patients (74.2%) had intraoperative confirmation of leak from the middle cranial fossa, involving the temporal bone, while 7 (22.6%) had leaks from the anterior skull base. One patient, who had dural enhancement, had an infratentorial CSF leak along the petrous segment of the internal carotid artery. CONCLUSIONS: Our study provides further evidence that skull base and spinal CSF leaks represent distinct pathophysiologies and present with different brain MRI findings.
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BACKGROUND AND PURPOSE: Cushing disease is typically caused by a pituitary adenoma that frequently is small and challenging to detect on conventional MR imaging. High-field-strength 7T MR imaging can leverage increased SNR and contrast-to-noise ratios compared with lower-field-strength MR imaging to help identify small pituitary lesions. We aimed to describe our institutional experience with 7T MR imaging in patients with Cushing disease and perform a review of the literature. MATERIALS AND METHODS: We performed a retrospective analysis of 7T MR imaging findings in patients with pathology-proved Cushing disease from a single institution, followed by a review of the literature on 7T MR imaging for Cushing disease. RESULTS: Our institutional experience identified Cushing adenomas in 10/13 (76.9%) patients on 7T; however, only 5/13 (38.5%) lesions were discrete. Overall, the imaging protocols used were heterogeneous in terms of contrast dose as well as type of postcontrast T1-weighted sequences (dynamic, 2D versus 3D, and type of 3D sequence). From our institutional data, specific postgadolinium T1-weighted sequences were helpful in identifying a surgical lesion as follows: dynamic contrast-enhanced, 2/7 (28.6%); 2D FSE, 4/8 (50%); 3D sampling perfection with application-optimized contrasts by using different flip angle evolution (SPACE), 5/6 (83.3%); and 3D MPRAGE, 8/11 (72.7%). The literature review identified Cushing adenomas in 31/33 (93.9%) patients on 7T. CONCLUSIONS: 7T MR imaging for pituitary lesion localization in Cushing disease is a new technique with imaging protocols that vary widely. Further comparative research is needed to identify the optimal imaging technique as well as assess the benefit of 7T over lower-field-strength MR imaging.
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Imageamento por Ressonância Magnética , Hipersecreção Hipofisária de ACTH , Humanos , Hipersecreção Hipofisária de ACTH/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Adulto , Feminino , Pessoa de Meia-Idade , Masculino , Estudos Retrospectivos , Adenoma/diagnóstico por imagem , Neoplasias Hipofisárias/diagnóstico por imagem , Idoso , Adulto JovemRESUMO
Post-dural puncture headache (PDPH) is an increasingly recognized cause of chronic headache. Outside of clinical history and myelography that requires an additional dural puncture, there is no reliable diagnostic test to evaluate for persistent dural defects. We describe the injection of iodinated contrast into the dorsal epidural space under CT guidance in five patients as a potential tool to visualize persistent dural defects.ABBREVIATIONS: PDPH = post-dural puncture headache; SIH = spontaneous intracranial hypotension; DSM = digital subtraction myelography; CTM = CT myelography.
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BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension is a condition resulting from a leak of CSF from the spinal canal arising independent of a medical procedure. Spontaneous intracranial hypotension can present with normal brain MR imaging findings and nonspecific symptoms, leading to the underdiagnosis in some patients and unnecessary invasive myelography in others who are found not to have the condition. Given the likelihood that spontaneous intracranial hypotension alters intracranial biomechanics, the goal of this study was to evaluate MR elastography as a potential noninvasive test to diagnose the condition. MATERIALS AND METHODS: We performed MR elastography in 15 patients with confirmed spontaneous intracranial hypotension from September 2022 to April 2023. Age, sex, symptom duration, and brain MR imaging Bern score were collected. MR elastography data were used to compute stiffness and damping ratio maps, and voxelwise modeling was performed to detect clusters of significant differences in mechanical properties between patients with spontaneous intracranial hypotension and healthy control participants. To evaluate diagnostic accuracy, we summarized each examination by 2 spatial pattern scores (one each for stiffness and damping ratio) and evaluated group-wise discrimination by receiver operating characteristic curve analysis. RESULTS: Patients with spontaneous intracranial hypotension exhibited significant differences in both stiffness and damping ratio (false discovery rate-corrected, Q < 0.05). Pattern analysis discriminated patients with spontaneous intracranial hypotension from healthy controls with an area under the curve of 0.97 overall, and the area under the curve was 0.97 in those without MR imaging findings of spontaneous intracranial hypotension. CONCLUSIONS: Results from this pilot study demonstrate MR elastography as a potential imaging biomarker and a noninvasive method for diagnosing spontaneous intracranial hypotension, including patients with normal brain MR imaging findings.
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Técnicas de Imagem por Elasticidade , Hipotensão Intracraniana , Imageamento por Ressonância Magnética , Humanos , Hipotensão Intracraniana/diagnóstico por imagem , Técnicas de Imagem por Elasticidade/métodos , Feminino , Masculino , Adulto , Pessoa de Meia-Idade , Imageamento por Ressonância Magnética/métodos , Idoso , Adulto JovemRESUMO
Photon-counting CT is an increasingly used technology with numerous advantages over conventional energy-integrating detector CT. These include superior spatial resolution, high temporal resolution, and inherent spectral imaging capabilities. Recently, photon-counting CT myelography was described as an effective technique for the detection of CSF-venous fistulas, a common cause of spontaneous intracranial hypotension. It is likely that photon-counting CT myelography will also have advantages for the localization of dural tears, a separate type of spontaneous spinal CSF leak that requires different myelographic techniques for accurate localization. To our knowledge, prior studies on photon-counting CT myelography have been limited to techniques for detecting CSF-venous fistulas. In this technical report, we describe our technique and early experience with photon-counting CT myelography for the localization of dural tears.
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Dura-Máter , Hipotensão Intracraniana , Mielografia , Tomografia Computadorizada por Raios X , Hipotensão Intracraniana/diagnóstico por imagem , Humanos , Mielografia/métodos , Dura-Máter/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Masculino , Feminino , Pessoa de Meia-Idade , FótonsRESUMO
BACKGROUND AND PURPOSE: Intracranial vessel wall imaging is technically challenging to implement, given the simultaneous requirements of high spatial resolution, excellent blood and CSF signal suppression, and clinically acceptable gradient times. Herein, we present our preliminary findings on the evaluation of a deep learning-optimized sequence using T1-weighted imaging. MATERIALS AND METHODS: Clinical and optimized deep learning-based image reconstruction T1 3D Sampling Perfection with Application optimized Contrast using different flip angle Evolution (SPACE) were evaluated, comparing noncontrast sequences in 10 healthy controls and postcontrast sequences in 5 consecutive patients. Images were reviewed on a Likert-like scale by 4 fellowship-trained neuroradiologists. Scores (range, 1-4) were separately assigned for 11 vessel segments in terms of vessel wall and lumen delineation. Additionally, images were evaluated in terms of overall background noise, image sharpness, and homogeneous CSF signal. Segment-wise scores were compared using paired samples t tests. RESULTS: The scan time for the clinical and deep learning-based image reconstruction sequences were 7:26 minutes and 5:23 minutes respectively. Deep learning-based image reconstruction images showed consistently higher wall signal and lumen visualization scores, with the differences being statistically significant in most vessel segments on both pre- and postcontrast images. Deep learning-based image reconstruction had lower background noise, higher image sharpness, and uniform CSF signal. Depiction of intracranial pathologies was better or similar on the deep learning-based image reconstruction. CONCLUSIONS: Our preliminary findings suggest that deep learning-based image reconstruction-optimized intracranial vessel wall imaging sequences may be helpful in achieving shorter gradient times with improved vessel wall visualization and overall image quality. These improvements may help with wider adoption of intracranial vessel wall imaging in clinical practice and should be further validated on a larger cohort.
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BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH. MATERIALS AND METHODS: A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated. RESULTS: 174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky). CONCLUSIONS: Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.
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Vazamento de Líquido Cefalorraquidiano , Hipotensão Intracraniana , Imageamento por Ressonância Magnética , Humanos , Feminino , Hipotensão Intracraniana/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Vazamento de Líquido Cefalorraquidiano/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Índice de Gravidade de Doença , Mielografia/métodos , Adulto , IdosoRESUMO
Dilated perivascular spaces (PVSs) are common and easily recognized on imaging. However, rarer giant tumefactive PVSs (GTPVSs) can have unusual multilocular cystic configurations, and are often confused for other pathologic entities, including neoplasms, cystic infarctions, and neuroepithelial cysts. Because GTPVSs are scarcely encountered and even more infrequently operated upon, many radiologists are unaware of the imaging and pathologic features of these lesions. Here, a case of a resected GTPVS is presented, highlighting both its radiologic and histologic characteristics, and discussing how such lesions can be differentiated from their closest mimickers on imaging.
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CSF-venous fistulas (CVFs) are a common cause of spontaneous intracranial hypotension. Despite their relatively frequent occurrence, they can be exceedingly difficult to detect on imaging. Since the initial description of CVFs in 2014, the recognition and diagnosis of this type of CSF leak has continually increased. As a result of multi-institutional efforts, a wide spectrum of imaging modalities and specialized techniques for CVF detection is now available. It is important for radiologists to be familiar with the multitude of available techniques, because each has unique advantages and drawbacks. In this article, we review the spectrum of imaging modalities available for the detection of CVFs, explain the advantages and disadvantages of each, provide typical imaging examples, and discuss provocative maneuvers that may improve the conspicuity of CVFs. Discussed modalities include conventional CT myelography, dynamic myelography, digital subtraction myelography, conebeam CT myelography, decubitus CT myelography by using conventional energy-integrating detector scanners, decubitus photon counting CT myelography, and intrathecal gadolinium MR myelography. Additional topics to be discussed include optimal patient positioning, respiratory techniques, and intrathecal pressure augmentation.
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SUMMARY: Spinal CSF leak care has considerably evolved over the past several years due to pivotal advances in its diagnosis and treatment. To the reader of the AJNR, it has been impossible to miss the exponential increase in groundbreaking research on spinal CSF leaks and spontaneous intracranial hypotension (SIH). While many clinical specialties have contributed to these successes, the neuroradiologist has been instrumental in driving this transformation due to innovations in non-invasive imaging, novel myelographic techniques, and imageguided therapies. In this editorial, we will delve into the exciting advancements in spinal CSF leak diagnosis and treatment and celebrate the vital role of the neuroradiologist at the forefront of this revolution, with particular attention to CSF leak related work published in the AJNR.ABBREVIATIONS: SIH = spontaneous intracranial hypotension; CVF = CSF-venous fistula; CTM = CT myelography; DSM = digital subtraction myelography; CB-CTM = conebeam CT myelography; PCD-CT = photon counting detector CT.
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Rathke cleft cysts are common cystic pituitary lesions seen on MR imaging. A subset of Rathke cleft cysts can rupture within the sella and are uncommon. The imaging appearance of a ruptured Rathke cleft cyst has been previously described with nonspecific imaging findings. We present 7 cases of ruptured Rathke cleft cysts and basisphenoid bone marrow enhancement below the sella that could be used to potentially distinguish a ruptured Rathke cleft cyst from other cystic lesions.