Numerous intracranial soft tissue and vascular structures are intimately related to the endocranial surface of the central skull base, including the pituitary gland, the pachymeninges, and multiple cranial nerves. These structures can give rise to pathologies that create imaging abnormalities along the bony surface of the skull base or result in gross changes of the underlying bone: hyperostosis, scalloping, permeation, erosion, or destruction. Large lesions with frank invasion may be difficult to differentiate from intrinsic bone lesions. This article reviews a variety of endocranial lesions affecting the central skull base, including the giant or invasive pituitary macroadenoma and skull base meningioma, and highlights the imaging features for a practical approach to their diagnosis.