Primary empty sella syndrome in a series of 142 patients

Persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery: A case report

BACKGROUND

Empty sella is an anatomical and radiological finding of the herniation of the subarachnoid space into the pituitary fossa leading to a flattened pituitary gland. Patients with empty sella may present with various symptoms, including headache due to intracranial hypertension and endocrine symptoms related to the specific pituitary hormones affected. Here, we report a female patient who developed persistent postoperative hypotension caused by subclinical empty sella syndrome after a simple surgery.

CASE SUMMARY

A 47-year-old woman underwent vocal cord polypectomy under general anesthesia with endotracheal intubation. She denied any medical history, and her vital signs were normal before the surgery. Anesthesia and surgery were uneventful. However, she developed dizziness, headache and persistent hypotension in the ward. Thus, intravenous dopamine was started to maintain normal blood pressure, which improved her symptoms. However, she remained dependent on dopamine for over 24 h without any obvious anesthesia- and surgery-related complications. An endocrine etiology was then suspected, and further examination showed a high prolactin level, a low normal adrenocorticotropic hormone level and a low cortisol level. Magnetic resonance imaging of the brain revealed an empty sella. Therefore, she was diagnosed with empty sella syndrome and secondary adrenal insufficiency. Her symptoms disappeared one week later after daily glucocorticoid supplement.

CONCLUSION

Endocrine etiologies such as pituitary and adrenal-related dysfunction should be considered in patients showing persistent postoperative hypotension when anesthesia- and surgery-related factors are excluded.

Cushing's Disease Associated With Partially Empty Sella Turcica Syndrome: A Case Report

The association between empty sella turcica (EST) syndrome and Cushing's disease has been rarely reported. It is plausible to hypothesize that EST syndrome in association with Cushing's disease can be attributed to intracranial hypertension. In this case report, we present a 47-year-old male patient who presented with weight loss, fatigue, easy bruising, acanthosis nigricans, and skin creases hyperpigmentation. Investigations revealed hypokalemia and confirmed the diagnosis of Cushing's disease. Magnetic resonance imaging (MRI) brain showed a partial EST syndrome and a new pituitary nodule as compared with previous brain imaging. Transsphenoidal surgery was pursued and was complicated by cerebrospinal fluid leakage. This case reflects the rare association of EST syndrome and Cushing's disease, suggesting the increased risk of postoperative complications in this setting and the diagnostic challenge that EST syndrome imposes. We review the literature for a possible mechanism of this association.

The Link Between Empty Sella Syndrome, Fibromyalgia, and Chronic Fatigue Syndrome: The Role of Increased Cerebrospinal Fluid Pressure

The etiopathogenesis of fibromyalgia (FM) and chronic fatigue syndrome (CFS) is not yet elucidated. Hypothalamo-pituitary-adrenal (HPA) axis dysfunction is reflected in the hormonal disturbances found in FM and CFS. Some study groups have introduced a novel hypothesis that moderate or intermittent intracranial hypertension may be involved in the etiopathogenesis of FM and CFS. In these conditions, hormonal disturbances may be caused by the mechanical effect of increased cerebrospinal fluid pressure, which hampers blood flow in the pituitary gland. Severe intracranial pressure may compress the pituitary gland, resulting in primary empty sella (ES), potentially leading to pituitary hormone deficiencies. The aim of this narrative review was to explore whether similar hormonal changes and symptoms exist between primary ES and FM or CFS and to link them to cerebrospinal fluid pressure dysregulation. A thorough search of the PubMed and Web of Science databases and the reference lists of the included studies revealed that several clinical characteristics were more prevalent in primary ES, FM or CFS patients than in controls, including increased cerebrospinal fluid pressure, obesity, female sex, headaches and migraine, fatigue, visual disturbances (visual acuity and eye motility abnormalities), vestibulocochlear disturbances (vertigo and neurosensorial hearing loss), and bodily pain (radicular pain and small-fiber neuropathy). Furthermore, challenge tests of the pituitary gland showed similar abnormalities in all three conditions: blunted adrenocorticotropic hormone, cortisol, growth hormone, luteinizing hormone, and thyroid stimulating hormone responses and an increased prolactin response. The findings of this narrative review provide further support for the hypothesis that moderately or intermittently increased cerebrospinal fluid pressure is involved in the pathogenesis of FM and CFS and should stimulate further research into the etiopathogenesis of these conditions.

Analysis of clinical features of primary empty sella

OBJECTIVE

A retrospective analysis of clinical data of 60 patients with primary empty sella (PES) was conducted to further improve the understanding of the disease.

METHODS

The clinical data of 60 patients diagnosed with PES admitted to the Department of Endocrinology of Wuhan Union Hospital for different reasons from January 2000 to September 2018 were analyzed.

RESULTS

The 60 cases comprised 22 (36.67%) male and 38 (63.33%) female patients, for a male-to-female ratio of 1:1.73. There was predominance of 50-59 year-olds and women with multiple pregnancies. Of the 60 patients, 41.67% showed fatigue, 26.67% dizziness and headache, 21.67% nausea and vomiting, 18.33% anorexia, and 6.67% visual impairment and other symptoms. Twenty-seven patients (45.0%) had normal pituitary function, and 33 (55.0%) had hypopituitarism. Complete PES was more prone to result in hypopituitarism than partial PES. Men with PES were more likely to have hypopituitarism than women.

CONCLUSION

The incidence of PES was significantly higher in women than in men; PES was common in middle-aged and older women with multiple pregnancies. Symptoms were diverse and clinical manifestations may lack specificity compared to other diseases and need to be differentiated. About half of PES patients may develop hypopituitarism. Therefore, for patients with empty sella detected on magnetic resonance imaging (MRI) with or without clinical symptoms, the pituitary function should be thoroughly and promptly evaluated.

Management of a Growth Hormone-Secreting Pituitary Macroadenoma Associated With Idiopathic Intracranial Hypertension and an Empty Sella

Idiopathic intracranial hypertension (IIH) is a -condition associated with elevated intracranial pressure (ICP) and frequently presents with headaches, papilledema, and visual loss. Rarely, IIH has been reported in association with acromegaly. Although removal of the tumor may reverse this process, elevated ICP, especially in the setting of an otherwise empty sella, may result in a cerebrospinal fluid (CSF) leak that is exceedingly difficult to manage. We present the first case of a patient with a functional pituitary adenoma causing acromegaly associated with IIH and an otherwise empty sella and discuss our management paradigm for this rare condition.

The Emptiness Within: A Case of Empty Sella Syndrome

Empty Sella syndrome (ESS) is characterized by the sella turcica being filled with cerebrospinal fluid (CSF), leading to partial or total compression of the pituitary gland, often resulting in hormonal deficiencies. It can be primary or secondary. In patients presenting with complaints of generalized weakness and fatiguability, with multiple episodes of prior hospitalizations, a thorough history and evaluation can lead to a diagnosis. We report a case of a 50-year-old lady with recurrent admissions for hyponatremia. Based on biochemical parameters and brain imaging, she was diagnosed to have ESS. We report this case to highlight the various diagnostic challenges associated with panhypopituitarism and the importance of having a high clinical suspicion, as the treatment is simple and lifesaving.

Relationship with the diaphragm to predict the surgical outcome in large and giant pituitary adenomas

Objective

Large and giant pituitary adenomas (L- and G-PAs) continue to remain a surgical challenge. The diaphragm may have a role in determining the shape of the tumor and therefore influencing the extent of resection. Our study aims to analyze our surgical series of L- and G-PAs according to their relationship with the diaphragm and invasion of cavernous sinus (CS).

Material and methods

We performed a retrospective analysis of our surgical series of patients operated for L- and G-PAs. We categorized the tumors into four grades according to their relationship with the diaphragm: grade 1 (supradiaphragmatic component with a wide incompetent diaphragm), grade 2 (purely infra-diaphragmatic tumor with a competent diaphragm), grade 3 (dumbbell-shape tumors), and grade 4 (multilobulated tumor with invasion of the subarachnoid space).

Results

A total of 37 patients were included in our analysis. According to our classification, 43.3% of patients had grade 1 tumors, 27% had grade 2, 5.4% had grade 3, and 24.3% had grade 4 tumors. CS invasion was confirmed intraoperatively in 17 out of 37 patients (46%). The gross total resection (GTR) was obtained in 19% of the cases, near-total resection in 46%, and subtotal resection in 35%. All the patients who achieved GTR had grade 1 tumors and the lowest rate of CS invasion (p < 0.01).

Conclusion

Radiological evaluation of the tumor relationship with the diaphragm, invasion of CS, and invasion of the subarachnoid space are crucial to plan the surgical strategy and maximize the possibilities of achieving GTR in L- and G-PAs.

ENDOCRINE OBESITY: Pituitary dysfunction in obesity

Obesity, the growing pandemic of the 21st century, is associated with multiple organ dysfunction, either by a direct increase in fatty organ content or by indirect modifications related to general metabolic changes driven by a specific increase in biologic products. The pituitary gland is not protected against such a situation. Different hypothalamic-pituitary axes experience functional modifications initially oriented to an adaptive situation that, with years of obesity, turn to maladaptive dynamics that contribute to perpetuating obesity and specific symptoms of their hormonal nature. This paper reviews the recent knowledge on obesity-related pituitary dysfunction and its pathogenic mechanisms and discusses potential therapeutic actions aimed at contributing to ameliorating the complex treatment of severe cases of obesity.

Radiographic pituitary stalk disruption: A rare sequela of secondary empty sella syndrome

Background:

This two-patient case series describes a rare sequela of postoperative empty sella syndrome (ESS) following transsphenoidal resection of pituitary macroadenomas. This is characterized by progressive hormone dysfunction, diabetes insipidus (DI), and associated MRI evidence of pituitary stalk disruption.

Case Description:

This phenomenon was retrospectively evaluated in a review of 2000 pituitary tumor resections performed by a single neurosurgeon (KOL). Chart review was retrospectively conducted to gather data on demographics, pituitary hormone status, tumor characteristics, and management. We identified 2 (0.1%) cases of progressive pituitary endocrine dysfunction occurring in the postoperative period associated with MRI evidence of pituitary stalk disruption within 6 weeks of discharge from the hospital. This was felt to be caused by the rapid descent of the residual normal pituitary gland down to the floor of the postoperative empty sella, causing relatively swift stalk stretching. Both patients developed DI, and one patient demonstrated increased pituitary hormone dysfunction.

Conclusion:

This phenomenon is a rare manifestation of postoperative ESS, secondary to surgical resection of a pituitary macroadenoma. We discuss the associated potential risk factors and strategies for avoidance in these two cases. Routine instillation of intrasellar fat in patients at risk is felt to be protective.

Pituitary Volume in Patients with Primary Empty Sella and Clinical Relevance to Pituitary Hormone Secretion: A Retrospective Single Center Study

Background

According to neuroradiological findings, empty sella seems to be deprived of pituitary tissue in sella turcica. Changing size of the pituitary volume is closely related to the occurrence of primary empty sella. The aim of the study is to determine pituitary dysfunction in patients with partial or total primary empty sella and the significance of pituitary volume measurements in these patients.

Methods

This study was designed retrospectively. 67 patients (55 females, 12 males) diagnosed with primary empty sella syndrome between the years of 2015-2019 were included in the study. Patients were divided into two groups: partial (PES) and total (TES) empty sella by magnetic resonance imaging (MRI). Basal anterior pituitary and its hormones were assessed. We also included 26 healthy control subjects (19 females, 7 males) to compare the differences in pituitary volumes. Volumes were measured by using Osirix Dicom Viewer (Pixmeo SARL, Geneve, Swiss) in 3.0 Tesla scanner MRI.

Results

82.1% (n=55) of all patients were PES and the others were (n=12) TES. Hypopituitarism, known as one or more pituitary hormones deficiency, was found in 12 patients (17.9%). While 9 of them had total PES, the others had partial PES. Secondary adrenal insufficiency and gonadotropin deficiency were more prevalent in patients with TES. Mean volume measurements of patients with TES, PES and healthy subjects were 0.23±0.17, 0.35±0.15, 0.54±0.17 cm³, respectively. Except for IGF1 values (p=0.026), there was not any significant correlation found between the anterior pituitary hormones and volume measurements.

Conclusion

Although volume measurement has helped in the diagnosis of pituitary empty sella (partial or total), it does not seem to have any significant correlation with pituitary secretory function.

Does pituitary compression/empty sella syndrome contribute to MRI-negative Cushing's disease? A single-institution experience

OBJECTIVE

Cushing's disease arises from functioning adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. These tumors can be very small and evade detection by MRI. Empty sella syndrome is a phenomenon by which an arachnoid outpouching of CSF into the sella leads to compression of the pituitary, likely due to intracranial hypertension (a common issue in Cushing's disease), further leading to difficulty in visualizing the pituitary gland that may contribute to difficulty in finding a tumor on MRI, so-called MRI-negative Cushing's disease. The authors sought to examine the association between empty sella syndrome and MRI-negative Cushing's disease.

METHODS

A single-institution database of Cushing's disease cases from 2000 to 2017 was reviewed, and 197 cases were included in the analysis. One hundred eighty patients had a tissue diagnosis of Cushing's disease and 17 had remission with surgery, but no definitive tissue diagnosis was obtained. Macroadenomas (tumors > 1 cm) were excluded. The degree of empty sella syndrome was graded on the degree of CSF visualized in the sella on midline sagittal T1-weighted MRI.

RESULTS

Of the 197 cases identified, 40 (20%) presented with MRI-negative disease, and empty sella syndrome was present in 49 cases (25%). MRI-negative disease was found in 18 (37%) of 49 empty sella cases versus 22 (15%) of 148 cases without empty sella syndrome present. Empty sella syndrome was significantly associated with MRI-negative disease (OR 3.32, 95% CI 1.61-6.74, p = 0.0018). Decreased thickness of the pituitary gland was also associated with MRI-negative disease (mean thickness 5.6 vs 6.8 mm, p = 0.0002).

CONCLUSIONS

Empty sella syndrome is associated with an increased rate of MRI-negative Cushing's disease. Pituitary compression causing a relative reduction in the volume of the pituitary for imaging is a plausible cause for not detecting the tumor mass with MRI.

Primary empty sella: The risk factors and associations with the cerebral small vessel diseases-An observational study

OBJECTIVE

To investigate the risk factors of primary empty sella (PES) and its associations with cerebral small vessel diseases (CSVD).

METHODS

A total of 132 consecutive patients were recruited from Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University from December 2018 to January 2020, including 69 cases of PES, and age, gender-matched 63 subjects without PES. Demographics and clinical characteristics were recorded. Enlarged perivascular spaces (PVS) and white matter hyperintensities (WMH), which are image markers for CSVD, were assessed. Univariate logistic regression models and multivariate logistic regression models were performed to predict the independent risk factors of PES.

RESULTS

There was a significant difference in baseline characteristics in terms of hypertension (p < 0.001) and pregnancy (p = 0.019) between PES and the control group; among markers of CSVD, whole WMH (p = 0.030) and periventricular hyperintensities (PVH) (p = 0.027) were significantly different; however, no significant differences concerning deep WMH, total PVS, basilar ganglia-PVS and centrum semiovale-PVS (p > 0.05). After adjusting relevant potential confounders, multivariate logistic regression revealed hypertension (OR=3.158, 95 %CI: 1.452∼6.865, p = 0.004) and pregnancy (OR=2.236, 95 %CI: 1.036-4.826, p = 0.040) were independent risk factors for PES.

CONCLUSION

Hypertension and pregnancy are independent risk factors of PES. There is a possible correlation between PES and WMH, especially PVH, however, further studies are required to confirm these findings.

Spontaneous Cerebrospinal Fluid Rhinorrhea from a Prolactin-Secreting Pituitary Macroadenoma

Cerebrospinal fluid (CSF) rhinorrhea is a rare complication of macroprolactinomas that, in the vast majority of cases, is subsequent to either medical or surgical intervention. Here, we present the successful management of a rare case of spontaneous, noniatrogenic CSF rhinorrhea in a patient with an untreated macroprolactinoma. A 27-year-old man with no significant medical history presented with six months of persistent CSF rhinorrhea, which was confirmed by testing for beta-2-transferrin. He had had decreased libido since adolescence and impaired growth of secondary sexual characteristics. Workup revealed an elevated prolactin level, and imaging demonstrated erosion of the anterior sellar floor and soft tissue within the sphenoid sinus, concerning for tumor. The patient underwent surgical repair of the CSF leak via a transnasal transsphenoidal approach, with resection and biopsy of tumor material within the sinus. No tumor was noted within the sella itself. The patient tolerated the procedure well and had subsequent normalization of his prolactin level with no further CSF egress. Spontaneous noniatrogenic CSF rhinorrhea, although rare, should be considered in the differential diagnosis of invasive pituitary macroadenomas, especially prolactinomas. The mechanism of CSF leak from a prolactinoma is not completely understood, but the CSF leak should be urgently repaired through a transnasal transsphenoidal approach. Concurrently, tumor resection should be performed and a postoperative lumbar puncture or lumbar drain should be considered to reinforce the skull base reconstruction.

Non-communicating hydrocephalus with a primary empty sella presenting with growth hormone deficiency and delayed puberty successfully treated by endoscopic third ventriculocisternostomy

The authors present the unusual case of a 15-year-old boy with a primary empty sella caused by non-communicating hydrocephalus due to fourth ventricle outflow obstruction whose secondary symptoms of growth hormone deficiency and delayed puberty were successfully treated by endoscopic third ventriculocisternostomy (ETV). Hypopituitarism occurs only rarely in cases of hydrocephalus; rarer still are cases where hypopituitarism is the sole symptom of hydrocephalus. A primary empty sella may indicate elevated intracranial pressure; if the cause is non-communicating hydrocephalus, ETV is indicated as the preferred treatment modality.

Primary Partial Empty Sella presenting with Prepubertal Hypogonadotropic Hypogonadism: A Case Report

Primary partial empty sella occurs when less than 50% of an enlarged or deformed sella turcica is filled with cerebrospinal fluid in the setting of unidentified etiologic pathological conditions. Prepubertal hypogonadotropic hypogonadism presenting as its main manifestation is rare since its peak incidence commonly occurs late at 30 to 40 years of age and has a sexual predilection for female. We described a case of 20-year-old male who presented with micropenis and absent secondary sex characteristics. Work up showed cranial MRI finding of partial empty sella, low testosterone, LH, FSH, Estradiol and Beta HCG levels. Sex hormone replacement may not improve fertility for this case but may help produce and maintain virilization and prevent future complications of hypogonadotropic hypogonadism.

Magnetic resonance imaging of the hypothalamo-pituitary region

The diagnosis and management of mass lesions in the sellar and parasellar areas remain challenging. When approaching patients with possible sellar or hypothalamic masses, it is important not only to focus on imaging but also detect possible pituitary hormone deficits or excess, in order to establish an appropriate diagnosis and initiate treatment. The imaging modalities used to characterize hypothalamic and pituitary lesions have significantly evolved over the course of the past several years. Computed tomography (CT) and CT angiography play a major role in detecting various sellar lesions, especially in patients who have contraindications to magnetic resonance imaging (MRI) and can also yield important information for surgical planning. However, MRI has become the gold standard for the detection and characterization of hypothalamic and pituitary tumors, infections, cystic, or vascular lesions. Indeed, the imaging characteristics of hypothalamic and sellar lesions can help narrow down the differential diagnosis preoperatively. In addition, MRI can help establish the relationship of mass lesions to surrounding structures. A pituitary MRI examination should be obtained if there is concern for mass effect (including visual loss, ophthalmoplegia, headache) or if there is clinical suspicion and laboratory evidence of either hypopituitarism or pituitary hormone excess. The information obtained from MRI images also provides us with assistance in planning surgery. Using intraoperative MRI can be very helpful in assessing the adequacy of tumor resection. In addition, MRI images yield reliable data that allow for noninvasive monitoring of patients postoperatively.

Empty sella syndrome: Multiple endocrine disorders

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.

Clinical presentation, evaluation and case management of primary empty sella syndrome: a retrospective analysis of 10-year single-center patient data

BACKGROUND

Primary Empty Sella (PES) syndrome is an increasingly common disorder, mostly diagnosed as an incidental finding during brain imaging scans. We intended to review the clinical management and hormonal profile of patients with PES.

METHODS

The study included ten-year retrospective analysis of registry containing PES cases in the period 2007 to 2017, from a single tertiary care center. The keyword 'primary empty sella' was used to retrieve patient details from the radiology unit. The clinical and biochemical profile of PES patients was analyzed. Case management of PES patients and their rate of referral to endocrinologists was explored.

RESULTS

The registry had 765 cases with a male: female ratio of 1:3.8 suggesting female predominance by almost four times. Although not significant, the onset of disease was earlier for males [Mean ± standard deviation (SD) (46.7 years ±17.3 vs 48.8 years±14.1), p = 0.110]. Almost 79% of the cases were found as an incidental finding during Magnetic Resonance Imaging. Of the total PES cases, only 20% were referred to the endocrinologists and the rest were handled by general physicians. Only 1-2.5% of the cases were evaluated for gonadal, growth and adrenal hormones by the general physicians. The hormonal evaluation by the endocrinologists was also found to be sub-optimal. Headache and visual disturbances were the most common presenting complaints followed by menstrual abnormalities. Endocrine abnormalities like thyroid dysfunction, hyperprolactinemia, hypogonadism and hypocortisolism were highly prevalent among those assessed.

CONCLUSION

There is a gross under-evaluation of hormonal assessment and minimal case-referral to Endocrinologists. PES is associated with varying degrees of hormonal dysfunction, and hence early assessment and management is needed. Establishing a standard protocol for diagnosis and case management is essential with the involvement of a multidisciplinary team consisting of endocrinologists, neurologists, primary care phys icians and ophthalmologists.

Tegmen attenuation in patients with idiopathic intracranial hypertension is progressive

OBJECTIVES

To prove that temporal bone tegmen attenuation in patients with idiopathic intracranial hypertension (IIH) is progressive.

STUDY DESIGN

Retrospective blind study at a tertiary academic medical center.

METHODS

Enrolled were medical records of patients with IIH that included at least two sequential computed tomography (CT) scans. The vertical distances between the floor of the middle fossa to the superior and lateral semicircular canals (SSC and LSC, respectively), to the scutum and minimal squama thickness were measured. The same measurements were made in scans of control subjects. The impact of demographics and metabolic variables including opening lumbar puncture (LP) pressure were evaluated.

RESULTS

Twenty medical records were enrolled. Median age at diagnosis was 21 years; 16 were females. The median body mass index (BMI) was 32 kg/m² . Initial LP pressure was 195 mm cerebrospinal fluid (CSF). The median time interval between CT scans was 58 months. A median attenuation of 0.35 mm and 0.25 mm over the right and left LSC and of 0.5 mm and 0.3 mm over the right and left scutum, was found, respectively. The thicknesses of the SSC and squama remained stable. No attenuation was present in controls. The opening pressure on initial LP (median 195 mm CSF), was positively correlated with the degree of tegmen attenuation, but the age at diagnosis and BMI were not.

CONCLUSIONS

Tegmen attenuation may be progressive in patients with idiopathic increased intracranial pressure and correlated with the opening pressure on LP. Tegmen defects and CSF leak should be looked for in these patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 2020.

Case Report: Pituitary Morphology and Function Are Preserved in Female Patients With Idiopathic Intracranial Hypertension Under Pharmacological Treatment

Idiopathic Intracranial Hypertension is a neurological disorder primarily affecting overweight women of childbearing age. It is often characterized by radiologic evidence of empty sella (ES), which is in turn frequently associated with pituitary dysfunction, with the somatotropic axis most commonly affected. No recent evidence is available relative to the presence of pituitary hormone deficiencies in adult patients with Idiopathic Intracranial Hypertension (IIH) under pharmacological therapy. We therefore explored pituitary function and morphology in a small cohort of female patients with IIH treated with acetazolamide. Fifteen female patients aged 42 ± 13 years with IIH lasting between 12 and 18 months were evaluated. All patients were affected by recurrent headaches in addition to visual changes of variable severity. IIH diagnosis was made after exclusion of other causes of raised intracranial pressure, and a specific ophthalmological evaluation was conducted to assess for the presence of papilledema. No particular endocrinological disturbances were detected during the enrolment visits, except for a high obesity prevalence (87%, BMI 35.16 ± 8.21 kg/m²), one case of total thyroidectomy for papillary thyroid carcinoma and two patients with irregular menses and mild hirsutism. All the participants underwent a pituitary MRI with contrast, and two different operators performed pituitary measurements in coronal and sagittal scans for morphologic assessment. Blood samples for the anterior pituitary axis evaluation were collected, and the somatotropic axis was further evaluated with a GHRH + Arginine test; other dynamic tests were performed in case of suspected hormonal deficiency. Despite ES being found in 73% of the patients, pituitary volume was preserved, ranging from 213.85 to 642.27mm³ (389.20 ± 125.53mm³); mean coronal pituitary height was 4.53 ± 1.33 mm. Overall, baseline anterior pituitary hormones levels were within normal ranges, and none of the patients with ES had an altered response to the GHRH + arginine stimulation test. We found one patient suffering from iatrogenic hyperthyroidism and two diagnosed with subclinical primary hypothyroidism due to Hashimoto's thyroiditis. Two young patients were suspected of having polycystic ovary syndrome, and they were therefore further investigated. In conclusion, this case series shows that, despite the high prevalence of ES, the pituitary function of IIH patients treated with acetazolamide is preserved. To date, there is no evidence regarding the trend over time or upon treatment discontinuation in regard to the pituitary function of patients with IIH, and it is therefore not possible to infer whether our finding would be replicable in such settings. We therefore suggest an endocrine follow-up over time in order to monitor for potential pituitary dysfunction.

Sinus Bradycardia as a Rare and Unusual Presentation of Partial Empty Sella Syndrome: A Case Report

BACKGROUND Empty sella syndrome (ESS) occurs when the pituitary gland becomes flattened or shrinks, which leads to filling of the sella turcica with cerebrospinal fluid. This causes the appearance of empty sella on imaging. ESS is often diagnosed after the workup of pituitary disorders, or as an incidental finding after brain imaging. To the best of our knowledge, this is the first case report in which ESS was diagnosed after an incidental finding of bradycardia pre-operatively. CASE REPORT We present the case of a 66-year-old man who was admitted electively to undergo a transforaminal lumbar interbody fusion at the level of L5-S1. He was found to be bradycardic pre-operatively. Upon further workup, he was found to have a thyroid-stimulating hormone (TSH) level of 0.358 uIU/ML (normal range, 0.465-4.680 uIU/ML) and a free thyroxine (FT4) level of 0.8 ng/dL (normal range, 0.8-2.2ng/dL). He also had a history of hypotestosteronemia. He was diagnosed with central hypothyroidism at the time of admission. Subsequently, a magnetic resonance imaging (MRI) scan of the brain was performed, and partial empty sella syndrome was diagnosed. CONCLUSIONS Bradycardia in the setting of empty sella syndrome is a rare condition. It is of utmost importance for clinicians to keep in mind a wide differential that includes other non-cardiac causes for common cardiac symptoms such as bradycardia.

Rare empty sella syndrome found after postoperative hypotension and respiratory failure: A case report

BACKGROUND

Empty sella syndrome is a condition in which the pituitary gland shrinks or flattens. Patients with empty sella syndrome often present with headache, hypertension, obesity, visual disturbances, cerebrospinal fluid (CSF) rhinorrhoea, or endocrine dysfunction. Herein, we report a rare case of empty sella syndrome discovered after the patient experienced postoperative hypotension and respiratory failure.

CASE SUMMARY

A 60-year-old man was admitted for further workup of left shoulder pain. He was assessed by the orthopaedics team and booked for internal fixation of the left clavicle. General anaesthesia with a nerve block was administered. His blood pressure continued to decrease post-operation. Endocrine tests were performed, with the results supporting a diagnosis of hypopituitarism with hypocortisolism and hypothyroidism. Brain magnetic resonance imaging demonstrated that the sella was enlarged and filled with CSF, confirming a diagnosis of empty sella syndrome. The patient was started on endocrine replacement therapy. The patient regained consciousness and spontaneous breath finally.

CONCLUSION

This case highlights the importance of considering pituitary hormone insufficiency in the context of respiratory and hemodynamic failure during the perioperative period.

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.

DIAGNOSIS OF ENDOCRINE DISEASE: Primary empty sella: a comprehensive review

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.

'Empty sella' on routine MRI studies: An incidental finding or otherwise?

BACKGROUND

Empty sella (ES) has been regarded as an incidental finding. Recently, there have been studies documenting association of ES with hormonal and non-hormonal abnormalities. To detect the prevalence of empty sella in routine MRI brain study and to find associations with other diseases.

METHODS

A retrospective study was carried out for patients undergoing MRI brain studies in the radiology department of a teaching institution. Patients with ES formed the study group. The rest formed the baseline population. Presence of nine select variables, viz. hormonal disturbances, headache, sensorineural hearing loss, seizures, vertigo, psychiatric disorders, visual disturbances, ataxia and raised intracranial tension, was analyzed amongst the study group, as well as the baseline population. Association of ES and the select variables was analyzed by determining means and proportions and using Chi-square test.

RESULTS

During the study period, a total of 12,414 patients underwent MRI brain studies at our centre. ES was found in 241 (1.94%) patients. The proportion of patients in the ES and non-empty sella groups for each of the variables were as follows: hormonal disturbances (3.31% vs 0.56%, P = .000), headache (8.3% vs 7.4%, P = .596), SNHL (3.7% vs 1.3%, P = .0010), seizure (6.2% vs 13%, P = .002), vertigo (4.6% vs 1.6%, P = .000), psychiatric disorders (4.6% vs 1.3%, P = .000), visual disturbances (2% vs 1.1%, P = .166), ataxia (1.7% vs 1.2%, P = .519) and raised ICT (2% vs 0.5%, P = .002).

CONCLUSION

Hormonal disturbances, psychiatric disorders, raised ICT and SNHL have been found to be more often associated with ES as compared to general population.

[Analysis of the joint and a posteriori probability between primary empty sella, its comorbidities and audiovestibular pathology]

BACKGROUND

Primary empty sella is a herniation of the sellar diaphragm into the pituitary space. It is an incidental finding and patients may manifest neurological, ophthalmological and/or endocrine disorders. Episodes of vertigo, dizziness, and hearing loss, have been reported.

OBJECTIVE

To determine the conditional probability, as well as the statistical dependency, through the Bayesian analysis in patients with primary empty sella and audiovestibular disorders.

PATIENTS

Individuals who attended the National Rehabilitation Institute from January 2010 to December 2011, diagnosed with primary empty sella and audiovestibular disorders.

MATERIAL AND METHODS

An analysis was performed on a sample of 18 patients with a diagnosis of primary empty sella confirmed with magnetic resonance studies and who had signs of vertigo, hearing loss and dizziness.

RESULTS

Of the 18 patients studied, 3 (16.66%) had primary empty sella as the only clinical evidence. In 9 patients (50%) empty sella was associated with vertigo, and 16 patients (88.88%) were diagnosed with hearing loss, with sensorineural hearing loss being the most frequent (77.77%). The intersection between the proportions of primary empty sella with the presence and type of hearing loss was calculated. Thus for sensorineural hearing loss, the calculated ratio was P(AB)=0.6912, and for conductive and mixed hearing loss the value of P(AB)=0.0493 in both cases.

CONCLUSIONS

Bayesian analysis and conditional probability enables the dependence between two or more variables to be calculated. In this study both mathematical models were used to analyse comorbidities and audiovestibular disorders in patients diagnosed with primary empty sella.

Orbital and intracranial effects of microgravity: findings at 3-T MR imaging

PURPOSE

To identify intraorbital and intracranial abnormalities in astronauts previously exposed to microgravity by using quantitative and qualitative magnetic resonance (MR) techniques.

MATERIALS AND METHODS

The institutional review board approved this HIPAA-compliant, retrospective review and waived the requirement for informed consent. Twenty-seven astronauts (mean age ± standard deviation, 48 years ± 4.5) underwent 3-T MR imaging with use of thin-section, three-dimensional, axial T2-weighted orbital and conventional brain sequences. Eight astronauts underwent repeat imaging after an additional mission in space. Optic nerve sheath diameter (ONSD) and optic nerve diameter (OND) were quantified in the retrolaminar optic nerve. OND and central optic nerve T2 hyperintensity were quantified at mid orbit. Qualitative analysis of the optic nerve sheath, optic disc, posterior globe, and pituitary gland morphology was performed and correlated for association with intracranial evidence of hydrocephalus, vasogenic edema, central venous thrombosis, and/or mass lesion. Statistical analyses included the paired t test, Mann-Whitney nonparametric test for group comparisons, Cronbach α coefficient for reproducibility, and Pearson correlation coefficient.

RESULTS

All astronauts had previous exposure to microgravity and, thus, control data were not available for comparison. The ONSD and OND ranged from 4.7 to 10.8 mm (mean, 6.2 mm ± 1.1) and from 2.4 to 4.5 mm (mean, 3.0 mm ± 0.5), respectively. Posterior globe flattening was seen in seven of the 27 astronauts (26%), optic nerve protrusion in four (15%), and moderate concavity of the pituitary dome with posterior stalk deviation in three (11%) without additional intracranial abnormalities. Retrolaminar OND increased linearly relative to ONSD (r = 0.797, Pearson correlation). A central area of T2 hyperintensity was identifiable in 26 of the 27 astronauts (96%) and increased in diameter in association with kinking of the optic nerve sheath.

CONCLUSION

Exposure to microgravity can result in a spectrum of intraorbital and intracranial findings similar to those in idiopathic intracranial hypertension.

Spontaneous CSF Leaks

Spontaneous cerebrospinal fluid rhinorrhea represents a distinct clinic entity that is likely a variant of idiopathic intracranial hypertension (IIH). Patients with spontaneous cerebrospinal fluid (CSF) leaks are generally middle-aged obese women with radiographic evidence of skull base defects, associated meningoencephaloceles, and empty sella syndrome, a common sign of increased intracranial pressure. Significant overlap exists in the characteristics of patients with spontaneous CSF leak and IIH. Endoscopic repair of the CSF fistula is the gold standard treatment for this condition, but emerging evidence supports the reduction of CSF pressure as an important adjuvant treatment in this patient population.

Primary spontaneous cerebrospinal fluid rhinorrhea: a symptom of idiopathic intracranial hypertension?

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.

Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus

OBJECT

Spontaneous meningoencephaloceles of the lateral sphenoid sinus are rare lesions that are hypothesized to result from persistence of the lateral craniopharyngeal canal. Prior reports of the management of this lesion have been limited by its relative rarity. The objective of this paper is to report the theoretical etiology, surgical technique, and outcomes in patients undergoing endoscopic repair of spontaneous meningoencephalocele of the sphenoid sinus.

METHODS

The authors conducted a retrospective review of a multiinstitutional series of 13 cases involving patients who underwent endoscopic repair of spontaneous meningoencephalocele of the lateral sphenoid sinus. The surgical technique and pathophysiological considerations are discussed.

RESULTS

The clinical manifestations included CSF rhinorrhea (85%), chronic headache (77%), and a history of meningitis (15%). The endoscopic approaches to the lateral sphenoid sinus were transnasal (39%), transpterygoid (23%), and transethmoid (39%). Two patients (8%) had postoperative CSF leaks, one of which closed spontaneously and one of which required revision endoscopic closure. All patients were free of leak at most recent follow-up. One patient experienced postoperative meningitis in the early postoperative period.

CONCLUSIONS

Endoscopic endonasal closure is an effective modality in the treatment of spontaneous meningoencephaloceles of the lateral sphenoid sinus. If the sphenoid sinus has extensive lateral pneumatization, adequate exposure may require a transpterygoid approach.

Analysis of empty sella secondary to the brain tumors

OBJECTIVE

The definition of empty sella syndrome is 'an anatomical entity in which the pituitary fossa is partially or completely filled with cerebrospinal fluid, while the pituitary gland is compressed against the posterior rim of the fossa'. Reports of this entities relating to the brain tumors not situated in the pituitary fossa, have rarely been reported.

METHODS

In order to analyze the incidence and relationship of empty sella in patients having brain tumors, the authors reviewed preoperative magnetic resonance imaging (MRI) of 72 patients with brain tumor regardless of pathology except the pituitary tumors. The patients were operated in single institute by one surgeon. There were 25 males and 47 females and mean patient age was 53 years old (range from 5 years to 84 years). Tumor volume was ranged from 2 cc to 238 cc.

RESULTS

The overall incidence of empty sella was positive in 57/72 cases (79.2%). Sorted by the pathology, empty sella was highest in meningioma (88.9%, p = 0.042). The empty sella was correlated with patient's increasing age (p = 0.003) and increasing tumor volume (p = 0.016).

CONCLUSION

Careful review of brain MRI with periodic follow up is necessary for the detection of secondary empty sella in patients with brain tumors. In patients with confirmed empty sella, follow up is mandatory for the management of hypopituitarism, cerebrospinal fluid (CSF) rhinorrhea, visual disturbance and increased intracranial pressure.

Empty sella syndrome, hyperadrenocorticism and megaoesophagus in a dachshund

A five-year-old, entire, male dachshund was presented with a five day history of hypersalivation and regurgitation as well as polyuria and polydipsia for several months. Chest radiographs demonstrated megaoesophagus and aspiration pneumonia. Furthermore, hyperadrenocorticism was demonstrated by means of elevations in levels of serum alkaline phosphatase and cholesterol, decreased urinary specific gravity, increased response to adrenocorticotropic hormone stimulation, insufficient suppression of the post-dexamethasone plasma cortisol levels, an increased endogenous adrenocorticotropic hormone concentration and bilaterally enlarged adrenal glands on abdominal ultrasound. The dog became severely dyspnoeic and was euthanased after magnetic resonance imaging was performed. The magnetic resonance imaging and necropsy revealed the sellar region mainly filled with fluid, with only small tissue remnants, a condition defined as empty sella syndrome in human medicine. To the author's knowledge, this is the first dog described with empty sella syndrome and only the second dog described with hyperadrenocorticism secondary to ectopic adrenocorticotropic hormone production. However, the association between empty sella syndrome and hyperadrenocorticism may be no more than incidental.