Extradural balloon obliteration of the empty sella report of three cases (intrasellar balloon obliteration)

Treatment of empty sella associated with visual impairment: a systematic review of chiasmapexy techniques

PURPOSE

Chiasmapexy is a poorly described surgical procedure adopted to correct the downward displacement of suprasellar visual system (SVS) into an empty sella (ES) causing visual worsening. The aim of our study is to define the indications for extradural and intradural chiasmapexy.

METHODS

A systematic literature review has been performed on MEDLINE database (US National Library of Medicine), including only articles that depicted cases of surgically treated patients affected by ES and progressive delayed visual worsening. Moreover, we have reported three cases of secondary ES syndrome (SESS) with visual worsening treated in our Department with transsphenoidal (TS) microsurgical intradural approach. Finally, we have compared the results of extradural and intradural chiasmapexy described in literature.

RESULTS

The etiology of visual impairment is different in primary and secondary ESS. In primary ESS (PESS) the only predisposing factor is a dehiscence of diaphragma sellae, and the anatomical distortion caused by displacement of optic chiasm or traction of pituitary stalk and infundibulum may determine a direct injury of neural fibers and ischemic damage of SVS. In PESS the mechanical elevation of SVS performed through extradural approach is sufficient to resolve the main pathologic mechanism. In SESS, arachnoidal adhesions play an important role in addition to downward herniation of SVS. Consequently, the surgical technique should provide elevation of SVS combined to intradural release of scar tissue and arachnoidal adhesions. In treatment of SESS, the intradural approaches result to be more effective, guaranteeing the best visual outcomes with the lowest complications rates.

CONCLUSIONS

The intradural chiasmapexy is indicated in treatment of SESS, instead the extradural approaches are suggested for surgical management of PESS.

Endoscopic transsphenoidal treatment of a prolactinoma patient with brain and optic chiasmal herniations

Bromocriptine has been the most widely used and effective agent to treat macroprolactinoma, and chiasmal herniation in a macroprolactinoma patient following the treatment with bromocriptine is a well-recognized complication. However, herniation of the inferior mesial frontal lobe into the sella has been rarely reported. The present clinical report is the second radiographic demonstration of herniation of the inferior mesial frontal lobe into the sella. After the treatment with transsphenoidal endoscopic chiasmopexy, the patient's visual disturbance improved dramatically. We suggest that transsphenoidal endoscopic chiasmopexy is an effective treatment option for the prolactinoma patient with brain and chiasmal herniations following the treatment with bromocriptine.

Treatment of empty sella syndrome with ventriculoperitoneal shunt

A symptomatic empty sella developed in a female patient undergoing bromocriptine therapy for microprolactinoma. Placement of a ventriculoperitoneal shunt dramatically improved the symptoms of headache and blurred vision. The post-operative imaging showed resolution of the empty sella. She was able to resume bromocriptine therapy without recurrence of her previous symptoms and give birth to a baby 20 months later. An MRI 44 months after surgery and on bromocriptine therapy showed no recurrence of the empty sella. We conclude that ventriculoperitoneal shunt may be a simple, and durable treatment for drug induced empty sella and allows resumption of bromocriptine therapy for preexisting microprolactinoma.

Endocrine Disturbances in Empty Sella Syndrome: Case Reports and Review of Literature

OBJECTIVE

To report 5 cases of empty sella syndrome (ESS) manifesting with various degrees of pituitary dysfunction.

METHODS

We describe the initial manifestations in 5 patients with primary ESS and in previous cases of ESS reported in the English language literature.

RESULTS

Review of our recent medical records identified 5 patients referred for evaluation of pituitary deficiencies in whom ESS was diagnosed. Glucocorticoid replacement was required in 3 patients, 2 of whom presented initially with symptoms of severe glucocorticoid deficiency. In each case, magnetic resonance imaging of the brain demonstrated an empty sella.

CONCLUSION

Our cases suggest that endocrine abnormalities are not rare as the initial manifestation of ESS and that, contrary to many studies in the literature, the endocrine abnormalities may be quite severe.

Endoscopic endonasal treatment of a spontaneous temporosphenoidal encephalocele with a detachable silicone balloon. Case report

Temporosphenoidal encephaloceles are rare entities that occur when the temporal lobe herniates into the sphenoid sinus through a skull base defect of the temporal bone. Both an iatrogenic and a traumatic pathogenesis have been proposed. The authors describe a spontaneously occurring temporosphenoidal encephalocele in a 63-year-old woman who had a 4-year history of rhinorrhea. Spiral computerized tomography (CT) scanning revealed a bone defect located inside the ophthalmomaxillary triangle. The intrasphenoidal encephalocele had a heterogeneously hypointense signal compared with cerebrospinal fluid (CSF) on T1-weighted magnetic resonance (MR) images and a hyperintense signal compared with CSF on T2-weighted MR images. Two previous endonasal endoscopic procedures, performed by ear, nose, and throat surgeons, had been unsuccessful. The authors performed an endoscopic endonasal right nostril procedure by using 0 degrees and 45 degrees rigid-lens endoscopes that were 4 mm in diameter and 18 cm long. The encephalocele in the sphenoid sinus was partially removed. DuraGen and fat graft were positioned in the bone defect. Two No. 2 French detachable silicone balloons (1.5 cm3 volume) inflated with surgical glue were introduced into the skull defect and into the sphenoid sinus, respectively. The CSF leakage stopped immediately. No nasal packing or postoperative CSF lumbar drainage was necessary. The patient did well. Postoperative CT and MR imaging, obtained at 24 hours and at 3 months, demonstrated that the balloon and the fat graft filled the bone defect and the sphenoid sinus. Eight months postprocedure no CSF leakage was observed. This appears to be the first case reported in the literature of a temporosphenoidal encephalocele successfully treated by an endoscopic endonasal technique involving packing of the defect with inflated detachable balloons.

Transsphenoidal treatment of empty sella by means of a silastic coil: technical note

OBJECTIVE AND IMPORTANCE

Several methods have been proposed to achieve transsphenoidal arachnoid mobilization and chiasmapexy in symptomatic empty sella (primary or secondary empty sella syndrome). These procedures are often difficult to perform and have not always had satisfactory long-term outcomes because of the difficulty of achieving adequate and long-lasting sellar filling over time. The volume of fat or muscle packing decreases over time as a result of scar retraction. The same problem may occur with intrasellar balloon placement because of deflation of the balloon.

TECHNIQUE

We propose extradural packing accomplished through a transsphenoidal approach, using a Silastic (Dow Corning, Auburn, MI) coil, fashioned by means of a ventricular catheter arranged as a spiral.

RESULTS

This technique was used in four patients with satisfactory and long-lasting clinical results. It presents several advantages over previous methods: it can be tailored to each patient; Silastic is an inert substance, and therefore scarring, with consequent shrinkage, does not occur; and because the coil is very elastic, it presents few risks of inflammatory complications or of excessive compression of sellar, parasellar, and suprasellar structures. Furthermore, this technique does not require a supplementary skin incision to harvest autologous tissues (fat, muscle, or fascia lata). A skilled neurosurgeon can perform the procedure in a few minutes with more ease and less expense than other techniques.

CONCLUSION

The reported technique is a valid alternative to classic transsphenoidal extradural packing.

Primary empty sella syndrome: the role of visual system herniation

BACKGROUND

It has been traditionally accepted that ophthalmologic alterations in cases of primary empty sella syndrome are caused by the herniation of the visual system in the pituitary fossa, but this cannot be stated categorically.

METHODS

Two female patients with primary empty sella syndrome and visual field defects were included in this series. The peculiarity of these cases was that in neither of them was there an evident herniation of the visual system. In the absence of other causes that could explain the visual defects, the patients were operated on through a transsphenoidal approach.

RESULTS

Both patients showed immediate improvement of their visual deficits without recurrence. Postoperative imaging studies have shown continuance of an adequate elevation of the sellar contents during the 5-year follow-up period.

CONCLUSIONS

Visual field defects in cases of primary empty sella syndrome may occur even without radiological evidence of herniation of the visual system. The fact that the two patients described in this paper improved after surgery supports other reports that in this syndrome traction on the infundibular stalk may cause some microscopic anatomic alteration in the visual system or in its vascular supply that is not evident on imaging studies.