Neuroendocrine Imaging

Variant: 1 Adult. Suspected or known hypofunctioning pituitary gland (hypopituitarism, growth hormone deficiency, growth deceleration, panhypopituitarism, hypogonadotropic hypogonadism). Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI sella without and with IV contrast	Usually Appropriate	O
MRI sella without IV contrast	Usually Appropriate	O
MRI sella with IV contrast	May Be Appropriate	O
CT sella with IV contrast	May Be Appropriate	☢☢☢
Radiography sella	Usually Not Appropriate	☢
Venous sampling petrosal sinus	Usually Not Appropriate	Varies
MRA head with IV contrast	Usually Not Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
CT sella without and with IV contrast	Usually Not Appropriate	☢☢☢
CT sella without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 2 Adult. Suspected or known hyperfunctioning pituitary adenoma (hyperthyroidism [high thyroid-stimulating hormone], Cushing syndrome [high adrenal corticotrophic hormone], hyperprolactinemia, acromegaly, or gigantism). Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI sella without and with IV contrast	Usually Appropriate	O
MRI sella without IV contrast	Usually Appropriate	O
MRI sella with IV contrast	May Be Appropriate	O
CT sella with IV contrast	May Be Appropriate	☢☢☢
CT sella without IV contrast	May Be Appropriate	☢☢☢
Radiography sella	Usually Not Appropriate	☢
Venous sampling petrosal sinus	Usually Not Appropriate	Varies
MRA head with IV contrast	Usually Not Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
CT sella without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 3 Adult. Diabetes insipidus. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI sella without and with IV contrast	Usually Appropriate	O
MRI sella without IV contrast	Usually Appropriate	O
MRI sella with IV contrast	May Be Appropriate	O
CT sella with IV contrast	May Be Appropriate	☢☢☢
CT sella without IV contrast	May Be Appropriate	☢☢☢
Radiography sella	Usually Not Appropriate	☢
Venous sampling petrosal sinus	Usually Not Appropriate	Varies
MRA head with IV contrast	Usually Not Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
CT sella without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 4 Adult. Pituitary apoplexy. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI sella without and with IV contrast	Usually Appropriate	O
MRI sella without IV contrast	Usually Appropriate	O
MRI sella with IV contrast	May Be Appropriate	O
CT sella with IV contrast	May Be Appropriate	☢☢☢
CT sella without IV contrast	May Be Appropriate (Disagreement)	☢☢☢
Radiography sella	Usually Not Appropriate	☢
Venous sampling petrosal sinus	Usually Not Appropriate	Varies
MRA head with IV contrast	Usually Not Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
CT sella without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 5 Adult. Surveillance postpituitary or sellar mass resection.

Procedure	Appropriateness Category	Relative Radiation Level
MRI sella without and with IV contrast	Usually Appropriate	O
MRI sella without IV contrast	Usually Appropriate	O
MRI sella with IV contrast	May Be Appropriate	O
CT sella with IV contrast	May Be Appropriate	☢☢☢
CT sella without IV contrast	May Be Appropriate	☢☢☢
Radiography sella	Usually Not Appropriate	☢
Venous sampling petrosal sinus	Usually Not Appropriate	Varies
MRA head with IV contrast	Usually Not Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
CT sella without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 6 Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI sella without and with IV contrast	Usually Appropriate	O
MRI sella without IV contrast	Usually Appropriate	O
MRI sella with IV contrast	May Be Appropriate	O
Radiography sella	Usually Not Appropriate	☢
Venous sampling petrosal sinus	Usually Not Appropriate	Varies
MRA head with IV contrast	Usually Not Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
CT sella with IV contrast	Usually Not Appropriate	☢☢☢
CT sella without and with IV contrast	Usually Not Appropriate	☢☢☢
CT sella without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢

Panel Members

Judah Burns, MD^a; Bruno Policeni, MD^b; Julie Bykowski, MD^c; Prachi Dubey, MBBS, MPH^d; Isabelle M. Germano, MD^e; Vikas Jain, MD^f; Amy F. Juliano, MD^g; Gul Moonis, MD^h; Matthew S. Parsons, MDⁱ; William J. Powers, MD^j; Tanya J. Rath, MD^k; Jason W. Schroeder, MD^l; Rathan M. Subramaniam, MD, PhD, MPH^m; M. Reza Taheri, MD, PhDⁿ; Matthew T. Whitehead, MD^o; David Zander, MD^p; Amanda S. Corey, MD^q.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: Adult. Suspected or known hypofunctioning pituitary gland (hypopituitarism, growth hormone deficiency, growth deceleration, panhypopituitarism, hypogonadotropic hypogonadism). Initial imaging.

Variant 2: Adult. Suspected or known hyperfunctioning pituitary adenoma (hyperthyroidism [high thyroid-stimulating hormone], Cushing syndrome [high adrenal corticotrophic hormone], hyperprolactinemia, acromegaly, or gigantism). Initial imaging.

Variant 3: Adult. Diabetes insipidus. Initial imaging.

Variant 3: Adult. Diabetes insipidus. Initial imaging.
A. CT sella

Variant 3: Adult. Diabetes insipidus. Initial imaging.
B. CTA head

Variant 3: Adult. Diabetes insipidus. Initial imaging.
C. MRA head

Variant 3: Adult. Diabetes insipidus. Initial imaging.
D. MRI sella

Variant 3: Adult. Diabetes insipidus. Initial imaging.
E. Radiography sella

Variant 3: Adult. Diabetes insipidus. Initial imaging.
F. Venous sampling petrosal sinus

Variant 4: Adult. Pituitary apoplexy. Initial imaging.

Variant 4: Adult. Pituitary apoplexy. Initial imaging.
A. CT sella

Variant 4: Adult. Pituitary apoplexy. Initial imaging.
B. CTA head

Variant 4: Adult. Pituitary apoplexy. Initial imaging.
C. MRA head

Variant 4: Adult. Pituitary apoplexy. Initial imaging.
D. MRI sella

Variant 4: Adult. Pituitary apoplexy. Initial imaging.
E. Radiography sella

Variant 4: Adult. Pituitary apoplexy. Initial imaging.
F. Venous sampling petrosal sinus

Variant 5: Adult. Surveillance postpituitary or sellar mass resection.

Variant 5: Adult. Surveillance postpituitary or sellar mass resection.
A. CT sella

Variant 5: Adult. Surveillance postpituitary or sellar mass resection.
B. CTA head

Variant 5: Adult. Surveillance postpituitary or sellar mass resection.
C. MRA head

Variant 5: Adult. Surveillance postpituitary or sellar mass resection.
D. MRI sella

Variant 5: Adult. Surveillance postpituitary or sellar mass resection.
E. Radiography sella

Variant 5: Adult. Surveillance postpituitary or sellar mass resection.
F. Venous sampling petrosal sinus

Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.

Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.
A. CT sella

Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.
B. CTA head

Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.
C. MRA head

Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.
D. MRI sella

Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.
E. Radiography sella

Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.
F. Venous sampling petrosal sinus

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

· ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

· ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

· ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

· ACR Manual on Contrast Media

· ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Bonneville JF.. Magnetic Resonance Imaging of Pituitary Tumors. [Review]. Front Horm Res. 45:97-120, 2016.
2.	Go JL, Rajamohan AG. Imaging of the Sella and Parasellar Region. [Review]. Radiol Clin North Am. 55(1):83-101, 2017 Jan.
3.	Wong A, Eloy JA, Couldwell WT, Liu JK. Update on prolactinomas. Part 1: Clinical manifestations and diagnostic challenges. [Review]. J Clin Neurosci. 22(10):1562-7, 2015 Oct.
4.	Esteves C, Neves C, Augusto L, et al. Pituitary incidentalomas: analysis of a neuroradiological cohort. Pituitary. 18(6):777-81, 2015 Dec.
5.	American College of Radiology. ACR Appropriateness Criteria®: Thyroid Disease. Available at: https://acsearch.acr.org/docs/3102386/Narrative/.
6.	Hoang JK, Hoffman AR, Gonzalez RG, et al. Management of Incidental Pituitary Findings on CT, MRI, and 18F-Fluorodeoxyglucose PET: A White Paper of the ACR Incidental Findings Committee. Journal of the American College of Radiology. 15(7):966-972, 2018 Jul.J. Am. Coll. Radiol.. 15(7):966-972, 2018 Jul.
7.	Eboli P, Shafa B, Mayberg M. Intraoperative computed tomography registration and electromagnetic neuronavigation for transsphenoidal pituitary surgery: accuracy and time effectiveness. J Neurosurg. 2011;114(2):329-335.
8.	Locatelli M, Di Cristofori A, Draghi R, et al. Is Complex Sphenoidal Sinus Anatomy a Contraindication to a Transsphenoidal Approach for Resection of Sellar Lesions? Case Series and Review of the Literature. [Review]. World Neurosurg. 100:173-179, 2017 Apr.
9.	Kupferman ME, Hanna E. Robotic surgery of the skull base. [Review]. Otolaryngol Clin North Am. 47(3):415-23, 2014 Jun.
10.	Garcia-Garrigos E, Arenas-Jimenez JJ, Monjas-Canovas I, et al. Transsphenoidal Approach in Endoscopic Endonasal Surgery for Skull Base Lesions: What Radiologists and Surgeons Need to Know. [Review]. Radiographics. 35(4):1170-85, 2015 Jul-Aug.Radiographics. 35(4):1170-85, 2015 Jul-Aug.
11.	Miki Y, Kanagaki M, Takahashi JA, et al. Evaluation of pituitary macroadenomas with multidetector-row CT (MDCT): comparison with MR imaging. Neuroradiology. 2007;49(4):327-333.
12.	Glastonbury CM, Osborn AG, Salzman KL. Masses and malformations of the third ventricle: normal anatomic relationships and differential diagnoses. Radiographics. 2011; 31(7):1889-1905.
13.	Patel SN, Youssef AS, Vale FL, Padhya TA. Re-evaluation of the role of image guidance in minimally invasive pituitary surgery: benefits and outcomes. Comput Aided Surg. 16(2):47-53, 2011.
14.	Isik S, Berker D, Tutuncu YA, et al. Clinical and radiological findings in macroprolactinemia. Endocrine. 2012; 41(2):327-333.
15.	Chakeres DW, Curtin A, Ford G. Magnetic resonance imaging of pituitary and parasellar abnormalities. Radiol Clin North Am. 1989; 27(2):265-281.
16.	Pisaneschi M, Kapoor G. Imaging the sella and parasellar region. Neuroimaging Clin N Am. 2005; 15(1):203-219.
17.	Spampinato MV, Castillo M. Congenital pathology of the pituitary gland and parasellar region. [Review] [43 refs]. Top Magn Reson Imaging. 16(4):269-76, 2005 Jul.
18.	Wu LM, Li YL, Yin YH, et al. Usefulness of dual-energy computed tomography imaging in the differential diagnosis of sellar meningiomas and pituitary adenomas: preliminary report. PLoS ONE. 9(3):e90658, 2014.
19.	Guitelman M, Garcia Basavilbaso N, Vitale M, et al. Primary empty sella (PES): a review of 175 cases. [Review]. Pituitary. 16(2):270-4, 2013 Jun.
20.	Macpherson P, Teasdale E, Hadley DM, Teasdale G. Invasive v non-invasive assessment of the carotid arteries prior to trans-sphenoidal surgery. Neuroradiology. 1987; 29(5):457-461.
21.	Heshmati HM, Fatourechi V, Dagam SA, Piepgras DG. Hypopituitarism caused by intrasellar aneurysms. Mayo Clinic Proceedings. 76(8):789-93, 2001 Aug.Mayo Clin Proc. 76(8):789-93, 2001 Aug.
22.	Weir B.. Pituitary tumors and aneurysms: case report and review of the literature. [Review] [70 refs]. Neurosurgery. 30(4):585-91, 1992 Apr.Neurosurgery. 30(4):585-91, 1992 Apr.
23.	Abele TA, Yetkin ZF, Raisanen JM, Mickey BE, Mendelsohn DB. Non-pituitary origin sellar tumours mimicking pituitary macroadenomas. [Review]. Clin Radiol. 67(8):821-7, 2012 Aug.
24.	Akhare PJ, Dagab AM, Alle RS, Shenoyd U, Garla V. Comparison of landmark identification and linear and angular measurements in conventional and digital cephalometry. Int J Comput Dent. 16(3):241-54, 2013.
25.	Bresson D, Herman P, Polivka M, Froelich S. Sellar Lesions/Pathology. [Review]. Otolaryngol Clin North Am. 49(1):63-93, 2016 Feb.
26.	Famini P, Maya MM, Melmed S. Pituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients. J Clin Endocrinol Metab. 96(6):1633-41, 2011 Jun.
27.	Hess CP, Dillon WP. Imaging the pituitary and parasellar region. Neurosurg Clin N Am. 2012;23(4):529-542.
28.	Dietemann JL, Cromero C, Tajahmady T, et al. CT and MRI of suprasellar lesions. J Neuroradiol. 1992; 19(1):1-22.
29.	Aleksandrov N, Audibert F, Bedard MJ, Mahone M, Goffinet F, Kadoch IJ. Gestational diabetes insipidus: a review of an underdiagnosed condition. J Obstet Gynaecol Can. 2010; 32(3):225-231.
30.	Argyropoulou M, Perignon F, Brauner R, Brunelle F. Magnetic resonance imaging in the diagnosis of growth hormone deficiency. J Pediatr. 1992; 120(6):886-891.
31.	Batista DL, Riar J, Keil M, Stratakis CA. Diagnostic tests for children who are referred for the investigation of Cushing syndrome. Pediatrics. 2007; 120(3):e575-586.
32.	Bihan H, Christozova V, Dumas JL, et al. Sarcoidosis: clinical, hormonal, and magnetic resonance imaging (MRI) manifestations of hypothalamic-pituitary disease in 9 patients and review of the literature. Medicine (Baltimore) 2007; 86(5):259-268.
33.	Bozzola M, Mengarda F, Sartirana P, Tato L, Chaussain JL. Long-term follow-up evaluation of magnetic resonance imaging in the prognosis of permanent GH deficiency. Eur J Endocrinol. 2000; 143(4):493-496.
34.	Castro LH, Ferreira LK, Teles LR, et al. Epilepsy syndromes associated with hypothalamic hamartomas. Seizure. 2007; 16(1):50-58.
35.	Cortet-Rudelli C, Sapin R, Bonneville JF, Brue T. Etiological diagnosis of hyperprolactinemia. Ann Endocrinol (Paris). 2007; 68(2-3):98-105.
36.	Delman BN, Fatterpekar GM, Law M, Naidich TP. Neuroimaging for the pediatric endocrinologist. Pediatr Endocrinol Rev. 2008; 5 Suppl 2:708-719.
37.	Donadio F, Barbieri A, Angioni R, et al. Patients with macroprolactinaemia: clinical and radiological features. Eur J Clin Invest. 2007; 37(7):552-557.
38.	Dutta P, Bhansali A, Singh P, Rajput R, Khandelwal N, Bhadada S. Congenital hypopituitarism: clinico-radiological correlation. J Pediatr Endocrinol Metab. 2009; 22(10):921-928.
39.	Ebner FH, Kuerschner V, Dietz K, Bueltmann E, Naegele T, Honegger J. Reduced intercarotid artery distance in acromegaly: pathophysiologic considerations and implications for transsphenoidal surgery. Surg Neurol. 2009; 72(5):456-460; discussion 460.
40.	Escourolle H, Abecassis JP, Bertagna X, et al. Comparison of computerized tomography and magnetic resonance imaging for the examination of the pituitary gland in patients with Cushing's disease. Clin Endocrinol (Oxf). 1993; 39(3):307-313.
41.	Friedman TC, Zuckerbraun E, Lee ML, Kabil MS, Shahinian H. Dynamic pituitary MRI has high sensitivity and specificity for the diagnosis of mild Cushing's syndrome and should be part of the initial workup. Horm Metab Res. 2007; 39(6):451-456.
42.	Garel C, Leger J. Contribution of magnetic resonance imaging in non-tumoral hypopituitarism in children. Horm Res. 2007; 67(4):194-202.
43.	Glezer A, Paraiba DB, Bronstein MD. Rare sellar lesions. Endocrinol Metab Clin North Am. 2008; 37(1):195-211, x.
44.	Jagannathan J, Kanter AS, Sheehan JP, Jane JA, Jr., Laws ER, Jr. Benign brain tumors: sellar/parasellar tumors. Neurol Clin. 2007; 25(4):1231-1249, xi.
45.	Johnson MR, Hoare RD, Cox T, et al. The evaluation of patients with a suspected pituitary microadenoma: computer tomography compared to magnetic resonance imaging. Clin Endocrinol (Oxf). 1992; 36(4):335-338.
46.	Kumar J, Kumar A, Sharma R, Vashisht S. Magnetic resonance imaging of sellar and suprasellar pathology: a pictorial review. Curr Probl Diagn Radiol. 2007; 36(6):227-236.
47.	Kunii N, Abe T, Kawamo M, Tanioka D, Izumiyama H, Moritani T. Rathke's cleft cysts: differentiation from other cystic lesions in the pituitary fossa by use of single-shot fast spin-echo diffusion-weighted MR imaging. Acta Neurochir (Wien). 2007; 149(8):759-769; discussion 769.
48.	Li G, Shao P, Sun X, Wang Q, Zhang L. Magnetic resonance imaging and pituitary function in children with panhypopituitarism. Horm Res Paediatr. 2010; 73(3):205-209. 20197674
49.	Longui CA, Rocha AJ, Menezes DM, et al. Fast acquisition sagittal T1 magnetic resonance imaging (FAST1-MRI): a new imaging approach for the diagnosis of growth hormone deficiency. J Pediatr Endocrinol Metab. 2004; 17(8):1111-1114.
50.	Lundin P, Bergstrom K, Thuomas KA, Lundberg PO, Muhr C. Comparison of MR imaging and CT in pituitary macroadenomas. Acta Radiol. 1991;32(3):189-196.
51.	Maghnie M, Triulzi F, Larizza D, et al. Hypothalamic-pituitary dwarfism: comparison between MR imaging and CT findings. Pediatr Radiol. 1990; 20(4):229-235.
52.	Maiya B, Newcombe V, Nortje J, et al. Magnetic resonance imaging changes in the pituitary gland following acute traumatic brain injury. Intensive Care Med. 2008; 34(3):468-475.
53.	Mehta A, Hindmarsh PC, Mehta H, et al. Congenital hypopituitarism: clinical, molecular and neuroradiological correlates. Clin Endocrinol (Oxf). 2009; 71(3):376-382.
54.	Molitch ME, Gillam MP. Lymphocytic hypophysitis. Horm Res. 2007; 68 Suppl 5:145-150.
55.	Murad-Kejbou S, Eggenberger E. Pituitary apoplexy: evaluation, management, and prognosis. Curr Opin Ophthalmol. 2009; 20(6):456-461.
56.	Pellini C, di Natale B, De Angelis R, et al. Growth hormone deficiency in children: role of magnetic resonance imaging in assessing aetiopathogenesis and prognosis in idiopathic hypopituitarism. Eur J Pediatr. 1990; 149(8):536-541.
57.	Rambaldini GM, Butalia S, Ezzat S, Kucharczyk W, Sawka AM. Clinical predictors of advanced sellar masses. Endocr Pract. 2007; 13(6):609-614.
58.	Rao VJ, James RA, Mitra D. Imaging characteristics of common suprasellar lesions with emphasis on MRI findings. Clin Radiol. 2008; 63(8):939-947.
59.	Rennert J, Doerfler A. Imaging of sellar and parasellar lesions. Clin Neurol Neurosurg. 2007; 109(2):111-124.
60.	Sahdev A, Reznek RH, Evanson J, Grossman AB. Imaging in Cushing's syndrome. Arq Bras Endocrinol Metabol. 2007; 51(8):1319-1328.
61.	Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, Stalla GK, Ghigo E. Hypopituitarism. Lancet. 2007; 369(9571):1461-1470.
62.	Cottier JP, Destrieux C, Brunereau L, et al. Cavernous sinus invasion by pituitary adenoma: MR imaging. Radiology. 215(2):463-9, 2000 May.Radiology. 215(2):463-9, 2000 May.
63.	Micko AS, Wohrer A, Wolfsberger S, Knosp E. Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. Journal of Neurosurgery. 122(4):803-11, 2015 Apr.J Neurosurg. 122(4):803-11, 2015 Apr.
64.	Macpherson P, Hadley DM, Teasdale E, Teasdale G. Pituitary microadenomas. Does Gadolinium enhance their demonstration? Neuroradiology. 1989; 31(4):293-298.
65.	Tripathi S, Ammini AC, Bhatia R, et al. Cushing's disease: pituitary imaging. Australas Radiol. 1994; 38(3):183-186.
66.	Deipolyi AR, Hirsch JA, Oklu R. Bilateral inferior petrosal sinus sampling. J Neurointerv Surg. 2011.
67.	Lopez J, Barcelo B, Lucas T, et al. Petrosal sinus sampling for diagnosis of Cushing's disease: evidence of false negative results. Clin Endocrinol (Oxf). 1996; 45(2):147-156.
68.	Shi X, Sun Q, Bian L, et al. Assessment of Bilateral Inferior Petrosal Sinus Sampling in the diagnosis and surgical treatment of the ACTH-dependent Cushing's syndrome: A comparison with other tests. Neuro Endocrinol Lett. 2011; 32(6):865-873.
69.	Isaacs RS, Donald PJ. Sphenoid and sellar tumors. Otolaryngol Clin North Am. 1995; 28(6):1191-1229.
70.	Bonneville JF, Cattin F, Dietemann JL. Hypothalamic-pituitary region: computed tomography imaging. Baillieres Clin Endocrinol Metab. 1989; 3(1):35-71.
71.	Carr DH, Sandler LM, Joplin GF. Computed tomography of sellar and parasellar lesions. Clin Radiol. 1984; 35(4):281-286.
72.	Harrison MJ, Morgello S, Post KD. Epithelial cystic lesions of the sellar and parasellar region: a continuum of ectodermal derivatives? J Neurosurg. 1994; 80(6):1018-1025.
73.	Hershey BL. Suprasellar masses: diagnosis and differential diagnosis. Semin Ultrasound CT MR. 1993; 14(3):215-231.
74.	Kakite S, Fujii S, Kurosaki M, et al. Three-dimensional gradient echo versus spin echo sequence in contrast-enhanced imaging of the pituitary gland at 3T. Eur J Radiol. 79(1):108-12, 2011 Jul.
75.	Nakazawa H, Shibamoto Y, Tsugawa T, et al. Efficacy of magnetic resonance imaging at 3 T compared with 1.5 T in small pituitary tumors for stereotactic radiosurgery planning. Jpn J Radiol. 32(1):22-9, 2014 Jan.
76.	Hughes JD, Fattahi N, Van Gompel J, Arani A, Ehman R, Huston J 3rd. Magnetic resonance elastography detects tumoral consistency in pituitary macroadenomas. Pituitary. 19(3):286-92, 2016 Jun.
77.	Heck A, Ringstad G, Fougner SL, et al. Intensity of pituitary adenoma on T2-weighted magnetic resonance imaging predicts the response to octreotide treatment in newly diagnosed acromegaly. Clin Endocrinol (Oxf). 77(1):72-8, 2012 Jul.
78.	Castillo M.. Pituitary gland: development, normal appearances, and magnetic resonance imaging protocols. [Review] [29 refs]. Top Magn Reson Imaging. 16(4):259-68, 2005 Jul.
79.	Gao R, Isoda H, Tanaka T, et al. Dynamic gadolinium-enhanced MR imaging of pituitary adenomas: usefulness of sequential sagittal and coronal plane images. Eur J Radiol. 39(3):139-46, 2001 Sep.
80.	Rand T, Lippitz P, Kink E, et al. Evaluation of pituitary microadenomas with dynamic MR imaging. Eur J Radiol. 41(2):131-5, 2002 Feb.
81.	Grober Y, Grober H, Wintermark M, Jane JA Jr, Oldfield EH. Comparison of MRI techniques for detecting microadenomas in Cushing's disease. J Neurosurg. 1-7, 2017 Apr 28.
82.	Chin BM, Orlandi RR, Wiggins RH 3rd. Evaluation of the sellar and parasellar regions. [Review]. Magn Reson Imaging Clin N Am. 20(3):515-43, 2012 Aug.
83.	Briet C, Salenave S, Bonneville JF, Laws ER, Chanson P. Pituitary Apoplexy. [Review]. Endocr Rev. 36(6):622-45, 2015 Dec.
84.	Tosaka M, Sato N, Hirato J, et al. Assessment of hemorrhage in pituitary macroadenoma by T2*-weighted gradient-echo MR imaging. AJNR Am J Neuroradiol. 28(10):2023-9, 2007 Nov-Dec.
85.	Sarwar KN, Huda MS, Van de Velde V, et al. The prevalence and natural history of pituitary hemorrhage in prolactinoma. J Clin Endocrinol Metab. 98(6):2362-7, 2013 Jun.
86.	Bladowska J, Biel A, Zimny A, et al. Are T2-weighted images more useful than T1-weighted contrast-enhanced images in assessment of postoperative sella and parasellar region?. Med Sci Monit. 17(10):MT83-90, 2011 Oct.
87.	Ziu M, Dunn IF, Hess C, et al. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Posttreatment Follow-up Evaluation of Patients With Nonfunctioning Pituitary Adenomas. [Review]. Neurosurgery. 79(4):E541-3, 2016 Oct.
88.	Kremer P, Forsting M, Ranaei G, et al. Magnetic resonance imaging after transsphenoidal surgery of clinically non-functional pituitary macroadenomas and its impact on detecting residual adenoma. Acta Neurochir (Wien). 144(5):433-43, 2002 May.
89.	Yoon PH, Kim DI, Jeon P, Lee SI, Lee SK, Kim SH. Pituitary adenomas: early postoperative MR imaging after transsphenoidal resection. AJNR Am J Neuroradiol. 22(6):1097-104, 2001 Jun-Jul.
90.	Coulter IC, Mukerji N, Bradey N, Connolly V, Kane PJ. Radiologic follow-up of non-functioning pituitary adenomas: rationale and cost effectiveness. J Neurooncol. 93(1):157-63, 2009 May.
91.	Kilic T, Ekinci G, Seker A, Elmaci I, Erzen C, Pamir MN. Determining optimal MRI follow-up after transsphenoidal surgery for pituitary adenoma: scan at 24 hours postsurgery provides reliable information. Acta Neurochir (Wien). 143(11):1103-26, 2001 Nov.
92.	Parrott J, Mullins ME. Postoperative imaging of the pituitary gland. [Review] [20 refs]. Top Magn Reson Imaging. 16(4):317-23, 2005 Jul.
93.	Huang KT, Bi WL, Smith TR, Zamani AA, Dunn IF, Laws ER Jr. Intrasellar abscess following pituitary surgery. Pituitary. 18(5):731-7, 2015 Oct.
94.	Ahmadipour Y, Lemonas E, Maslehaty H, et al. Critical analysis of anatomical landmarks within the sphenoid sinus for transsphenoidal surgery. Eur Arch Otorhinolaryngol. 273(11):3929-3936, 2016 Nov.
95.	Chen X, Dai J, Ai L, et al. Clival invasion on multi-detector CT in 390 pituitary macroadenomas: correlation with sex, subtype and rates of operative complication and recurrence. AJNR Am J Neuroradiol. 32(4):785-9, 2011 Apr.
96.	Eroukhmanoff J, Tejedor I, Potorac I, et al. MRI follow-up is unnecessary in patients with macroprolactinomas and long-term normal prolactin levels on dopamine agonist treatment. EUR. J. ENDOCRINOL.. 176(3):323-328, 2017 Mar.
97.	Hassan HA, Bessar MA, Herzallah IR, Laury AM, Arnaout MM, Basha MAA. Diagnostic value of early postoperative MRI and diffusion-weighted imaging following trans-sphenoidal resection of non-functioning pituitary macroadenomas. Clinical Radiology. 73(6):535-541, 2018 Jun.Clin Radiol. 73(6):535-541, 2018 Jun.
98.	Debeneix C, Bourgeois M, Trivin C, Sainte-Rose C, Brauner R. Hypothalamic hamartoma: comparison of clinical presentation and magnetic resonance images. Horm Res. 2001; 56(1-2):12-18.
99.	Freeman JL, Coleman LT, Wellard RM, et al. MR imaging and spectroscopic study of epileptogenic hypothalamic hamartomas: analysis of 72 cases. AJNR Am J Neuroradiol. 2004; 25(3):450-462.
100.	Grunt JA, Midyett LK, Simon SD, Lowe L. When should cranial magnetic resonance imaging be used in girls with early sexual development? J Pediatr Endocrinol Metab. 2004; 17(5):775-780.
101.	Iorgi ND, Allegri AE, Napoli F, et al. The use of neuroimaging for assessing disorders of pituitary development. Clin Endocrinol (Oxf). 2012; 76(2):161-176.
102.	Ng SM, Kumar Y, Cody D, Smith CS, Didi M. Cranial MRI scans are indicated in all girls with central precocious puberty. Arch Dis Child. 2003; 88(5):414-418; discussion 414-418.
103.	Zucchini S, di Natale B, Ambrosetto P, De Angelis R, Cacciari E, Chiumello G. Role of magnetic resonance imaging in hypothalamic-pituitary disorders. Horm Res. 1995; 44 Suppl 3:8-14.
104.	Carel JC, Eugster EA, Rogol A, et al. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. [Review] [125 refs]. Pediatrics. 123(4):e752-62, 2009 Apr.
105.	Chung EM, Biko DM, Schroeder JW, Cube R, Conran RM. From the radiologic pathology archives: precocious puberty: radiologic-pathologic correlation. Radiographics. 32(7):2071-99, 2012 Nov-Dec.
106.	Choi KH, Chung SJ, Kang MJ, et al. Boys with precocious or early puberty: incidence of pathological brain magnetic resonance imaging findings and factors related to newly developed brain lesions. Ann. pediatr. endocrinol. metab.. 18(4):183-90, 2013 Dec.
107.	Kaplowitz PB.. Do 6-8 year old girls with central precocious puberty need routine brain imaging?. Int J Pediatr Endocrinol. 2016:9, 2016.
108.	Klein DA, Emerick JE, Sylvester JE, Vogt KS. Disorders of Puberty: An Approach to Diagnosis and Management. [Review]. Am Fam Physician. 96(9):590-599, 2017 Nov 01.
109.	Mogensen SS, Aksglaede L, Mouritsen A, et al. Pathological and incidental findings on brain MRI in a single-center study of 229 consecutive girls with early or precocious puberty. PLoS ONE. 7(1):e29829, 2012.
110.	Pedicelli S, Alessio P, Scire G, Cappa M, Cianfarani S. Routine screening by brain magnetic resonance imaging is not indicated in every girl with onset of puberty between the ages of 6 and 8 years. J Clin Endocrinol Metab. 99(12):4455-61, 2014 Dec.
111.	Rieth KG, Comite F, Dwyer AJ, et al. CT of cerebral abnormalities in precocious puberty. AJR Am J Roentgenol. 148(6):1231-8, 1987 Jun.
112.	Carel JC, Leger J. Clinical practice. Precocious puberty. [Review] [55 refs]. N Engl J Med. 358(22):2366-77, 2008 May 29.
113.	Oatman OJ, McClellan DR, Olson ML, Garcia-Filion P. Endocrine and pubertal disturbances in optic nerve hypoplasia, from infancy to adolescence. Int J Pediatr Endocrinol. 2015(1):8, 2015.
114.	American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=89+&releaseId=2.
115.	American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=23+&releaseId=2.
116.	American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=28+&releaseId=2.
117.	American College of Radiology. Manual on Contrast Media. Available at: http://www.acr.org/Quality-Safety/Resources/Contrast-Manual.
118.	Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 37(3):501-30, 2013 Mar.
119.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.