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Chiloiro S, Giampietro A, Bianchi A, De Marinis L. Empty sella syndrome: Multiple endocrine disorders. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:29-40. [PMID: 34238465 DOI: 10.1016/b978-0-12-820683-6.00003-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Empty sella is a pituitary disorder characterized by the herniation of the subarachnoid space within the sella turcica. This is often associated with a variable degree of flattening of the pituitary gland. Empty sella has to be distinguished in primary and secondary forms. Primary empty sella (PES) excludes any history of previous pituitary pathologies such as previous surgical, pharmacologic, or radiotherapy treatment of the sellar region. PES is considered an idiopathic disease and may be associated with idiopathic intracranial hypertension. Secondary empty sella, however, may occur after the treatment of pituitary tumors through neurosurgery or drugs or radiotherapy, after spontaneous necrosis (ischemia or hemorrhage) of chiefly adenomas, after pituitary infectious processes, pituitary autoimmune diseases, or brain trauma. Empty sella, in the majority of cases, is only a neuroradiological finding, without any clinical implication. However, empty sella syndrome is defined in the presence of pituitary hormonal dysfunction (more frequently hypopituitarism) and/or neurological symptoms due to the possible coexisting of idiopathic intracranial hypertension. Empty sella syndrome represents a peculiar clinical entity, characterized by heterogeneity both in clinical manifestations and in hormonal alterations, sometimes reaching severe extremes. For a proper diagnosis, management, and follow-up of empty sella syndrome, a multidisciplinary approach with the integration of endocrine, neurological, and ophthalmological experts is strongly advocated.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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Dallan I, Cambi C, Emanuelli E, Cazzador D, Canevari FR, Borsetto D, Tysome JR, Donnelly NP, Rigante M, Georgalas C, Alobid I, Molteni G, Marchioni D, Shahzada AK, Scarano M, Seccia V, Pasquini E. Multiple spontaneous skull base cerebrospinal fluid leaks: some insights from an international retrospective collaborative study. Eur Arch Otorhinolaryngol 2020; 277:3357-3363. [PMID: 32725273 DOI: 10.1007/s00405-020-06227-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Spontaneous skull base cerebrospinal fluid leaks occurring without any apparent cause are rare. But those patients that present such leaks simultaneously, or successively, in multiple locations are even rarer. Given the rarity of this condition, we collected data from other groups in a multicentre study to reach an adequate number of patients and draw some preliminary considerations. METHODS We carried out a multicentre retrospective study on a cohort of patients treated at third level hospitals in Italy, Spain, United Kingdom and Greece for multiple spontaneous-CSF leaks and we compared them with a control group of patients treated for recurrent spontaneous-CSF leaks. Data regarding clinical aspects, radiological findings, surgical techniques and outcome were collected and preliminary considerations on the results were discussed. RESULTS A total of 25 patients presented multiple simultaneous spontaneous CSF leaks while 18 patients fit with the criteria of recurrent spontaneous CSF leaks. Data analysis was conducted separately. CONCLUSIONS Our understanding of the pathogenesis of this condition is currently very limited. A causative role of IIH may be present but the differences that emerged from the comparison with patients with recurrent fistulas seem to promote the possible role of other cofactors. A longer follow-up period is needed, and, in our opinion, prospective and multicentre studies are the only solution to seriously deal with such a complex topic.
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Affiliation(s)
- Iacopo Dallan
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy
| | - Christina Cambi
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy.
| | | | | | - Frank Rikki Canevari
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Daniele Borsetto
- Department of Skull Base Surgery, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - James R Tysome
- Department of Skull Base Surgery, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Neil P Donnelly
- Department of Skull Base Surgery, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Mario Rigante
- ENT Department, University of Perugia, Perugia, Italy
| | - Christos Georgalas
- Rhinology and Endoscopic Skull Base Unit, Hygeia Hospital, Athens, Greece
| | - Isam Alobid
- Rhinology and Skull Base Unit, Department of Otorhinolaryngology, Hospital Clínic, Barcelona, Spain
| | - Gabriele Molteni
- Otorhinolaryngology-Head and Neck Surgery, Department of Surgery, University Hospital of Verona, Verona, Italy
| | - Daniele Marchioni
- Otorhinolaryngology-Head and Neck Surgery, Department of Surgery, University Hospital of Verona, Verona, Italy
| | | | - Mariella Scarano
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy
| | - Veronica Seccia
- ENT Unit, Azienda Ospedaliero-Universitaria Pisana, Cisanello Hospital, Via Paradisa, 2, 56126, Pisa, Italy
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Schlosser RJ, Wilensky EM, Grady MS, Bolger WE. Elevated Intracranial Pressures in Spontaneous Cerebrospinal Fluid Leaks. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240301700403] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Spontaneous cerebrospinal fluid (CSF) leak is a condition that previously has been considered idiopathic and classified as having “normal” intracranial pressure (ICP). We present clinical and radiographic evidence that indicates elevated ICP in this group. In addition, we review the pathophysiology and unique management issues in caring for patients with spontaneous CSF leak. Methods We present a retrospective review of medical records, imaging studies, ICP measurements, and surgical treatment of patients with spontaneous CSF leaks. Results Sixteen patients with spontaneous CSF leaks were surgically treated from 1996 to 2002. Ten patients underwent postoperative lumbar puncture with CSF pressure measurement during clinically indicated computed tomography cisternograms. Intracranial pressures were elevated in all 10 patients, with a mean of 26.5 cm H2O and a range of 17.3–34 cm H2O, (normal, 0–15 cm H2O). Demographically, 13/16 patients were women, all were middle-aged with a mean age of 49.6 years, and 15/16 patients were obese with a mean body mass index of 35.9 kg/m2. Radiographically, 15 patients had imaging of the sella turcica, 10 patients had completely empty sellas, and 5 patients had partially empty sellas. Surgical repair was 100% successful in leak cessation with a mean follow-up of 14.1 months. Conclusion Although the precise cause and mechanism of spontaneous CSF leaks is not fully understood, this study sheds light on important factors to consider. Patients with this condition have similar physical and radiographic findings such as middle-aged, female gender, obesity, and empty sella. Additional investigation is needed to determine the exact cause of the condition, its relationship to elevated ICPs, and if further medical or surgical treatments to correct the intracranial hypertension are warranted.
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Affiliation(s)
- Rodney J. Schlosser
- Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | | | - M. Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William E. Bolger
- Department of Surgery (Otolaryngology), Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Schlosser RJ, Bolger WE. Spontaneous Nasal Cerebrospinal Fluid Leaks and Empty Sella Syndrome: A Clinical Association. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240301700205] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Spontaneous, idiopathic nasal meningoencephaloceles are herniations of arachnoid/dura and cerebrospinal fluid (CSF) through anatomically fragile sites within the skull base. Empty sella syndrome occurs when intracranial contents herniate through the sellar diaphragm filling the sella turcica with CSF and giving the radiographic appearance of an absent pituitary gland. The objective of this study was to examine the association between spontaneous encephaloceles/CSF leaks and empty sella syndrome because of their similar clinical features and potential common pathophysiology. Methods Retrospective. Results Sixteen patients were treated for spontaneous encephaloceles between 1996 and 2001. All 16 patients had associated CSF leaks. Five patients had multiple simultaneous encephaloceles. Fifteen patients with imaging of the sella turcica had empty (10 patients) or partially empty (5 patients) sellas. One patient did not have complete imaging of the sella. Three patients had lumbar punctures with measurement of CSF pressure during computed tomography cisternograms because of multiple skull base defects. Mean CSF pressure was 28.3 cm of water (range, 19–34 cm; normal, 0–15 cm). Thirteen of 16 patients (81%) were obese women (mean body mass index, 35.9 kg/m2; normal, <25 kg/m2). Mean follow-up was 14.2 months with 100% success in closure of the defects after one procedure. Conclusion Spontaneous meningoencephaloceles and CSF leaks are strongly associated with radiographic findings of an empty sella and suggest a common pathophysiology. The underlying condition probably represents a form of intracranial hypertension that exerts hydrostatic pressure at anatomically weakened sites within the skull base. Otolaryngologists should be familiar with this disease entity and the implications intracranial hypertension has on patient management.
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Affiliation(s)
- Rodney J. Schlosser
- Uniformed Services University of the Health Sciences, Bethesda, Maryland Presented at the American Rhinologic Society Meeting, Boca Raton, Florida, May 11, 2002
| | - William E. Bolger
- Uniformed Services University of the Health Sciences, Bethesda, Maryland Presented at the American Rhinologic Society Meeting, Boca Raton, Florida, May 11, 2002
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Chiloiro S, Giampietro A, Bianchi A, Tartaglione T, Capobianco A, Anile C, De Marinis L. DIAGNOSIS OF ENDOCRINE DISEASE: Primary empty sella: a comprehensive review. Eur J Endocrinol 2017; 177:R275-R285. [PMID: 28780516 DOI: 10.1530/eje-17-0505] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/23/2017] [Accepted: 07/31/2017] [Indexed: 01/23/2023]
Abstract
Primary empty sella (PES) is characterized by the herniation of the subarachnoid space within the sella, which is often associated with variable degrees of flattening of the pituitary gland in patients without previous pituitary pathologies. PES pathogenetic mechanisms are not well known but seem to be due to a sellar diaphragm incompetence, associated to the occurrence of upper sellar or pituitary factors, as intracranial hypertension and change of pituitary volume. As PES represents in a majority of cases, a neuroradiological findings without any clinical implication, the occurrence of endocrine, neurological and opthalmological symptoms, due to the above describes anatomical alteration, which delineates from the so called PES syndrome. Headache, irregular menses, overweight/obesity and visual disturbances compose the typical picture of PES syndrome and can be the manifestation of an intracranial hypertension, often associated with PES. Although hyperprolactinemia and growth hormone deficit represent the most common endocrine abnormalities, PES syndrome is characterized by heterogeneity both in clinical manifestation and hormonal alterations and can sometime reach severe extremes, as occurrence of papilledema, cerebrospinal fluid rhinorrhea and worsening of visual acuity. Consequently, a multidisciplinary approach, with the integration of endocrine, neurologic and ophthalmologic expertise, is strongly advocated and recommended for a properly diagnosis, management, treatment and follow-up of PES syndrome and all of the related abnormalities.
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Affiliation(s)
- S Chiloiro
- Pituitary Unit, Department of Endocrinology
| | | | - A Bianchi
- Pituitary Unit, Department of Endocrinology
| | | | | | - C Anile
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Agostino Gemelli Foundation, Rome, Italy
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Lobo BC, Baumanis MM, Nelson RF. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review. Laryngoscope Investig Otolaryngol 2017; 2:215-224. [PMID: 29094066 PMCID: PMC5655559 DOI: 10.1002/lio2.75] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/07/2017] [Accepted: 02/21/2017] [Indexed: 11/18/2022] Open
Abstract
Objectives To review the safety and efficacy of surgical management for spontaneous cerebrospinal fluid (CSF) leaks of the anterior and lateral skull base. Data Sources A systematic review of English articles using MEDLINE. Review Methods Search terms included spontaneous, CSF, cerebrospinal fluid, endoscopic, middle fossa, transmastoid, leak, rhinorrhea. Independent extraction of articles by 3 authors. Results Patients with spontaneous CSF leaks are often obese (average BMI of 38 kg/m2) and female (72%). Many patients also have obstructive sleep apnea (∼45%) and many have elevated intracranial pressure when measured by lumbar puncture. In addition to thinning of the skull base, radiographic studies also demonstrate cortical bone thinning. Endoscopic surgical repair of anterior skull base leaks and middle cranial fossa (MCF) approach for repair of lateral skull base leaks are safe and effective with an average short‐term failure rate of 9% and 6.5%, respectively. Long‐term failure rates are low. One randomized trial failed to show improved success of anterior leak repairs with the use of a lumbar drain (LD) (95% with vs. 92% without; P = 0.2). In a large retrospective cohort of MCF lateral skull base repairs, perioperative LD use was not necessary in >94% of patients. Conclusions Spontaneous CSF leaks are associated with female gender, obesity, increased intracranial hypertension, and obstructive sleep apnea. Endoscopic repair of anterior skull base leaks and MCF or transmastoid approaches for lateral skull base leaks have a high success rate of repair. In most cases, intraoperative placement of lumbar drain did not appear to result in improved success rates for either anterior or lateral skull base leaks. Level of Evidence 2a, Systematic Review.
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Affiliation(s)
- Brian C Lobo
- Head and Neck Institute, Cleveland Clinic Foundation Cleveland Ohio U.S.A
| | - Maraya M Baumanis
- Department of Otolaryngology-Head and Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A
| | - Rick F Nelson
- Department of Otolaryngology-Head and Neck Surgery Indiana University School of Medicine Indianapolis Indiana U.S.A.,Head and Neck Institute, Cleveland Clinic Foundation Cleveland Ohio U.S.A
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Schlosser RJ, Woodworth BA, Wilensky EM, Grady MS, Bolger WE. Spontaneous Cerebrospinal Fluid Leaks: A Variant of Benign Intracranial Hypertension. Ann Otol Rhinol Laryngol 2016; 115:495-500. [PMID: 16900803 DOI: 10.1177/000348940611500703] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Previous reports indicate that elevated intracranial pressure (ICP) may cause spontaneous cerebrospinal fluid (CSF) leaks. In this study we examined the clinical diagnosis of benign intracranial hypertension (BIH) in this population using the modified Dandy criteria. Methods: We performed a retrospective review of clinical data and measurements of ICPs after surgical repair. Results: Sixteen patients with spontaneous CSF leaks were surgically treated from 1996 to 2002. In 11 patients with CSF pressure measurements, strict adherence to the modified Dandy criteria definitively confirmed a diagnosis of BIH in 8 patients (72%) and a likely diagnosis in the 3 remaining patients. The mean ICP was 31.1 cm H2O (range, 17.3 to 52 cm H2O), and 81% of the patients were obese middle-aged women. Clinically, all patients had signs and/or symptoms of elevated ICP, such as headache (91%), pulsatile tinnitus (45%), hypertension (45%), balance problems (27%), and visual complaints (18%). Surgical repair was 100% successful in leak cessation over a mean follow-up of 14.1 months. Conclusions: Most patients with spontaneous CSF leaks fulfill the modified Dandy criteria; thus, this disorder appears to be a variant of BIH. Further investigation is needed to determine the exact cause of elevated CSF pressures in this group and whether medical or surgical treatments to correct the intracranial hypertension are warranted.
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Affiliation(s)
- Rodney J Schlosser
- Dept of Otolaryngology-Head and Neck Surgery, 135 Rutledge Ave, Suite 1130, PO Box 250550, Medical University of South Carolina, Charleston, SC 29425, USA
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Çavusoglu M, Duran S, Hatipoglu HG, Ciliz DS, Elverici E, Sakman B. Petrous apex cephalocoele: contribution of coexisting intracranial pathologies to the aetiopathogenesis. Br J Radiol 2015; 88:20140721. [PMID: 25651410 DOI: 10.1259/bjr.20140721] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to show the MRI findings of petrous apex cephalocoele (PAC) and the other intracranial pathologies that coexist with PAC, and to discuss the contribution of the co-existing pathologies to aetiopathogenesis. METHODS A retrospective analysis of our imaging archive for the period from January 2012 to October 2013 revealed 13 patients with PAC (12 females and 1 male; age range, 26-69 years). 11 patients underwent MRI examination of the cranium, and 2 patients underwent MRI examination of the sellar region. We evaluated the lesions for content, signal intensity, enhancement, relation to petrous apex and Meckel's cave. Images were also evaluated for coexisting pathologies. RESULTS The presenting symptoms included headache, vertigo, cerebrospinal fluid (CSF) leak and trigeminal neuropathy. All patients had PAC. All lesions were located posterolateral to the Meckel's cave and were isointense with CSF signal on all pulse sequences. All lesions were continuous with Meckel's cave. Coexisting pathologies included intracranial aneurysmal dilatation, empty sella, mass in hypophysis, arachnoid cyst, inferior herniation of parahippocampal gyrus and optic nerve sheath CSF distension. CONCLUSION Coexistence with other intracranial pathologies supports the possibility of CSF imbalance and/or intracranial hypertension in the aetiopathogenesis of PAC. ADVANCES IN KNOWLEDGE This study examined the contribution of the co-existing intracranial pathologies to the aetiopathogenesis of PAC.
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Affiliation(s)
- M Çavusoglu
- Department of Radiology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Chaaban MR, Illing E, Riley KO, Woodworth BA. Spontaneous cerebrospinal fluid leak repair: A five‐year prospective evaluation. Laryngoscope 2013; 124:70-5. [DOI: 10.1002/lary.24160] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 02/26/2013] [Accepted: 03/25/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Mohamad R. Chaaban
- Department of Surgery, Division of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirmingham Alabama U.S.A
| | - Elisa Illing
- Department of Surgery, Division of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirmingham Alabama U.S.A
| | - Kristen O. Riley
- Division of NeurosurgeryUniversity of Alabama at BirminghamBirmingham Alabama U.S.A
| | - Bradford A. Woodworth
- Department of Surgery, Division of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirmingham Alabama U.S.A
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Chaaban MR, Illing E, Riley KO, Woodworth BA. Acetazolamide for high intracranial pressure cerebrospinal fluid leaks. Int Forum Allergy Rhinol 2013; 3:718-21. [DOI: 10.1002/alr.21188] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 04/17/2013] [Accepted: 04/30/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Mohamad R. Chaaban
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; University of Alabama at Birmingham; Birmingham AL
| | - Elisa Illing
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; University of Alabama at Birmingham; Birmingham AL
| | - Kristen O. Riley
- Department of Surgery, Division of Neurosurgery; University of Alabama at Birmingham; Birmingham AL
| | - Bradford A. Woodworth
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery; University of Alabama at Birmingham; Birmingham AL
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Wright BLC, Lai JTF, Sinclair AJ. Cerebrospinal fluid and lumbar puncture: a practical review. J Neurol 2012; 259:1530-45. [DOI: 10.1007/s00415-012-6413-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/19/2011] [Accepted: 01/05/2012] [Indexed: 01/07/2023]
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Ramakrishnan VR, Suh JD, Chiu AG, Palmer JN. Reliability of preoperative assessment of cerebrospinal fluid pressure in the management of spontaneous cerebrospinal fluid leaks and encephaloceles. Int Forum Allergy Rhinol 2011; 1:201-5. [DOI: 10.1002/alr.20010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 09/09/2010] [Accepted: 09/11/2010] [Indexed: 11/07/2022]
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Yang Z, Wang B, Wang C, Liu P. Primary spontaneous cerebrospinal fluid rhinorrhea: a symptom of idiopathic intracranial hypertension? J Neurosurg 2011; 115:165-70. [PMID: 21476806 DOI: 10.3171/2011.3.jns101447] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors aim to identify the characteristics of primary spontaneous CSF rhinorrhea and propose a hypothesis for its pathogenesis. METHODS Between 2003 and 2009, 21 patients diagnosed with primary spontaneous CSF rhinorrhea underwent surgery in the authors' hospital. The clinical aspects were retrospectively reviewed, and their characteristics were analyzed. RESULTS There were 18 women and 3 men, whose ages ranged from 37 to 74 years (mean 53 years). Body mass index (BMI) ranged from 22 to 58.8 kg/m(2) (mean 31.2 kg/m(2)). Eighteen patients (85.7%) were overweight, and 18 (85.7%) suffered from headache or tinnitus before rhinorrhea. Radiological images revealed fully or partially empty sellae in 14 patients (66.7%). The preoperative intracranial pressure (ICP) ranged from 11 to 28 cm H(2)O (mean 17.6 cm H(2)O), while the postoperative ICP ranged from 21 to 32 cm H(2)O (mean 25.5 cm H(2)O, p < 0.01). An endoscope-assisted transnasal approach was chosen for the repair. Postoperatively, in 95.2% of patients a cure was achieved. Rhinorrhea recurred in only 1 patient, and a leakage from a new defect occurred in another patient 4 years after the operation. Both patients underwent additional surgery, which was successful. The follow-up period varied from 5 to 75 months with a mean of 34 months. CONCLUSIONS All patients had direct or indirect evidence of elevated ICP, most patients presented with symptoms of idiopathic intracranial hypertension (IIH), and most patients were women and obese. Primary spontaneous CSF rhinorrhea may be due to IIH, and it is a rare symptom of IIH. When treating or monitoring these patients during follow-up, ICP should be controlled, and other symptoms of IIH should be noted.
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Affiliation(s)
- Zhijun Yang
- Department of Neurosurgery, Beijing Neurosurgical Institution of Capital Medical University, Chongwen District, Beijing, People’s Republic of China
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Abstract
OBJECT The primary empty sella syndrome (ESS) represents a heterogeneous clinical picture characterized by endocrine disturbances and signs of intracranial hypertension. An increase in intracranial pressure (ICP) is proposed to be one of the involved pathogenetic factors. METHODS The series included 142 patients who were observed during a period of 20 years. All patients underwent an ICP and cerebrospinal fluid (CSF) dynamics evaluation through the use of a lumbar constant-rate infusion test. Impairment of ICP and CSF dynamics was observed in 109 patients (76.8%). In 35 of the 36 patients affected by severe intracranial hypertension without rhinorrhea, improvement in adverse neurological symptoms was achieved after implanting a CSF shunt. Visual function, already seriously compromised before surgery, remained severely altered in one patient. In the group of 34 patients affected by rhinorrhea, CSF leakage was controlled using different surgical treatments: CSF shunt placement in 16 cases, surgical repair of the sellar floor in three, and both procedures in the remaining 13. Two patients refused any surgical treatment. CONCLUSIONS The role of increased ICP in the pathogenesis and perpetuation of primary ESS has been confirmed. Adverse neurological signs and a CSF leak are correlated with an actual increase in ICP and are relieved after CSF shunt insertion. Cerebrospinal fluid rhinorrhea is more common than generally thought. Its resolution can be achieved using a careful diagnostic protocol and sometimes may require different surgical procedures.
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Affiliation(s)
- Giulio Maira
- Institute of Neurosurgery, Catholic University, Rome, Italy
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15
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Schlosser RJ, Bolger WE. Significance of empty sella in cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2003; 128:32-8. [PMID: 12574756 DOI: 10.1067/mhn.2003.43] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The role of elevated cerebrospinal fluid (CSF) pressures in the pathophysiology of various CSF leaks is not clear. Empty sella syndrome (ESS) is a radiographic finding that can be associated with elevated CSF pressures and may represent a radiographic indicator of intracranial hypertension. We present our experience with CSF leaks of various causes, the prevalence of ESS in the spontaneous and nonspontaneous categories, and the potential pathophysiology and unique management issues of the spontaneous CSF leak group. METHODS We conducted a retrospective review of medical records, imaging studies, and surgical treatment of CSF leaks in patients treated by the senior author. RESULTS Sixteen patients with spontaneous CSF leaks and 12 patients with nonspontaneous CSF leaks were surgically treated from 1996 through 2002. In the spontaneous group, 15 patients had complete imaging of the sella turcica. Ten had completely empty sellae and 5 had partially empty sellae, for a total of 100% (15 of 15). In the nonspontaneous group, 9 patients had complete imaging of the sella. Only 11% (1 of 9) had a partially empty sella and that was a congenital leak. Comparison of proportions between these 2 groups was significant (P = 0.01). The spontaneous group consisted primarily of obese, middle-aged females (13 of 16 patients). CONCLUSION Empty sella probably represents a sign of elevated intracranial pressure that leads to idiopathic, spontaneous CSF leaks. Spontaneous CSF leaks are strongly associated with the radiographic finding of an empty sella and are more common in obese females, similar to benign intracranial hypertension. This unique population may require more aggressive surgical and medical treatment to prevent recurrent or multiple leaks.
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Affiliation(s)
- Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
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De Paepe L, Abs R, Verlooy J, Clemens A, Smets RM, Louis P, Martin JJ. Benign intracranial hypertension as a cause of transient partial pituitary deficiency. J Neurol Sci 1993; 114:152-5. [PMID: 8445396 DOI: 10.1016/0022-510x(93)90290-f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A male patient is reported with benign intracranial hypertension, who presented with three periods of partial pituitary deficiency, corresponding to episodes of headaches and papilledema. No radiological signs of the empty sella syndrome were observed. Since benign intracranial hypertension has been implicated in the development of the empty sella syndrome, it is postulated that the endocrine deficiency syndrome encountered in the empty sella syndrome can be provoked by chronic intracranial hypertension in itself and is not necessarily secondary to the anatomical changes occurring in the sellar region.
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Affiliation(s)
- L De Paepe
- Department of Endocrinology, University of Antwerp, Belgium
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Maira G, Anile C, De Marinis L, Mancini A, Barbarino A. Cerebrospinal fluid pressure and prolactin in empty sella syndrome. Neurol Sci 1990; 17:92-4. [PMID: 2107018 DOI: 10.1017/s0317167100030122] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In 58 female patients with the primary empty sella (PES) syndrome, a study of the CSF dynamics was done by evaluating both the absorptive reserve by a lumbar infusion test at constant rate, and/or the ICP increase occurring during REM phase of nocturnal physiological sleep. In 33, prolactin (PRL) dynamics were also investigated evaluating both the response to sequential stimulating test with thyrotropin-releasing hormone (TRH) and metoclopramide (MCP) and/or the circadian variation of PRL levels. Impairment of CSF dynamics was found in the 84% who had a hormonal pattern characterized by an increase of the PRL response to TRH and MCP and a decrease of the PRL circadian variation. Twenty-one patients with impaired CSF dynamics underwent CSF shunting procedures with disappearance of the signs of intracranial hypertension. They also had restoration of normal PRL dynamics but the endocrine alterations improved only moderately. Altered CSF dynamics play a role in the pathogenesis of the PES syndrome. A correlation between elevated ICP and the hypothalamo-hypophyseal control of PRL secretion may exist.
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Affiliation(s)
- G Maira
- Institute of Neurosurgery, Catholic University, Rome, Italy
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Salvador J, Dieguez C, Scanlon MF. The circadian rhythms of thyrotrophin and prolactin secretion. Chronobiol Int 1988; 5:85-93. [PMID: 2897252 DOI: 10.3109/07420528809078555] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
As with other anterior pituitary hormones, the secretion of both thyrotrophin (TSH) and prolactin (PRL) displays a circadian variation with different patterns for each hormone. In recent years there has been a substantial increase in the understanding of the neuroregulation of TSH and PRL. However the primary events involved in the generation of their circadian rhythms remains unclear. Regulatory pathways comprise two major groups: central factors, where the control is exerted by the central nervous system via the hypothalamus and peripheral factors, which include all extra CNS mechanisms. The first group is represented mainly by neuropeptides and neurotransmitters controlling TSH and PRL release, whereas the second one comprises both physical phenomena such as variations in plasma volume or postural changes and hormonal influences arising from target glands such as the adrenal, the thyroid and the gonads.
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Affiliation(s)
- J Salvador
- Depto de Endocrinologia, Clinica Universitaria, Pamplona, Spain
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Celani MF, Giambuzzi G, Simoni M, Montanini V. Subnormal prolactin responsiveness to thyrotropin-releasing hormone (TRH) in women with primary empty sella syndrome. J Endocrinol Invest 1987; 10:421-5. [PMID: 3119699 DOI: 10.1007/bf03348162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Basal prolactin (PRL) levels and PRL responsiveness to thyrotropin-releasing hormone (TRH) were studied in 10 women with primary empty sella (PES) syndrome (mean age 38.2 yr). Hyperprolactinemia (34 to 72 ng/ml) was found in 5 patients (hyperprolactinemic PES, H-PES), whereas 5 patients showed normal (9.5 to 19 ng/ml) PRL levels (normoprolactinemic PES, N-PES). The results were compared with those obtained in 10 healthy women (mean age 32.8 yr, PRL = 7 to 15 ng/ml) and in 8 women with a PRL-secreting pituitary microadenoma (MA) (mean age 37.5 yr, PRL = 39 to 85 ng/ml). The mean basal levels of PRL were significantly higher in patients with H-PES (50.8 +/- 13.2 ng/ml) or MA (64.0 +/- 18.3 ng/ml) than in the control group (10.9 +/- 2.6 ng/ml, p less than 0.02) and in the patients with N-PES (13.9 +/- 3.7 ng/ml, p less than 0.02). In contrast, the relative maximum response (RMR) of PRL to TRH (peak PRL/basal PRL) was significantly lower in the patients with PES (both H-PES and N-PES) or MA (1.4 +/- 0.4, 2.3 +/- 0.7 and 1.2 +/- 0.2, respectively) than in the control subjects (3.6 +/- 1.1; p less than 0.02, less than 0.05 and less than 0.02, respectively). Our results show that the pituitary responsiveness to the acute stimulation with TRH is significantly decreased both in patients with a PRL-secreting pituitary MA and in those with PES. Therefore, the clinical value of the TRH test in distinguishing the PES syndromes from prolactinomas seems to be questionable.
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Affiliation(s)
- M F Celani
- Cattedra di Endocrinologia, Università di Modena, Italy
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