A Comprehensive Review of Empty Sella and Empty Sella Syndrome

OBJECTIVE

Incidental radiographic findings of an empty sella are prevalent in up to 35% of the general population. While empty sella was initially considered clinically insignificant, a subset of patients exhibits endocrine or neuro-ophthalmologic manifestations which are diagnostic of empty sella syndrome (ESS). Recent studies suggest that more patients are affected by ESS than previously recognized, necessitating a deeper understanding of this condition. This comprehensive review describes a practical approach to evaluating and managing ESS.

METHODS

Literature review was conducted on etiologies and risk factors associated with primary and secondary empty sella, the radiologic features that differentiate empty sella from other sellar lesions, and the role of clinical history and hormone testing in identifying patients with ESS, as well as treatment modalities.

RESULTS

Pituitary function testing for somatotroph, lactotroph, gonadotroph, corticotroph, and thyrotroph abnormalities is necessary when suspecting ESS. While an isolated empty sella finding does not require treatment, ESS may require pharmacologic or surgical interventions to address hormone deficits or intracranial hypertension. Targeted hormone replacement as directed by the endocrinologist should align with guidelines and patient-specific needs. Treatment may involve a multidisciplinary collaboration with neurology, neurosurgery, or ophthalmology to address patient symptoms.

CONCLUSION

This review underscores the evolving understanding of ESS, stressing the significance of accurate diagnosis and tailored management to mitigate potential neurologic and endocrine complications in affected individuals.

A case of Empty Sella syndrome with adrenal insufficiency masked by prednisolone after administration of immune checkpoint inhibitors

INTRODUCTION

The use of immune checkpoint inhibitors (ICIs) is gradually increasing; ICIs produce a variety of immune-related adverse events (irAEs), especially ICI-induced hypoadrenocorticism, which can be a lethal complication if treatment is delayed.

PATIENT CONCERNS

A 63-year-old man received chemotherapy with pembrolizumab for nonsmall cell lung cancer. He developed drug-induced interstitial pneumonia 366 days after receiving pembrolizumab and was treated with prednisolone. Five hundred thirty-seven days later, he developed drug-induced eosinophilic enteritis, and pembrolizumab was discontinued and prednisolone was continued. After discontinuation of prednisolone, general malaise and edema of the lower extremities appeared, and adrenal insufficiency was suspected.

DIAGNOSIS

In blood tests on admission adrenocorticotropic hormone (ACTH) was 2.2 pg/mL and cortisol was 15 μg/dL, with no apparent cortisol deficiency. However, the cortisol circadian rhythm disappeared and remained low throughout the day; a corticotropin-releasing hormone stimulation test showed decreased reactive secretion of ACTH. Pituitary magnetic resonance imaging showed pituitary emptying, suggesting Empty Sella syndrome.

INTERVENTIONS AND OUTCOMES

We started hydrocortisone and his symptoms were improved.

CONCLUSIONS

The administration of high-dose steroids after ICI administration may mask the symptoms of hypoadrenocorticism as irAEs. Therefore, we should bear in mind the possibility of hypoadrenocorticism when we stop steroid therapy in patients who are treated with steroids after ICI administration.

Heritable Pulmonary Arterial Hypertension in a Patient With Empty Sella Syndrome: A Case Report

Pulmonary arterial hypertension (PAH) is a progressive disease with multiple contributing factors. Genetics, epigenetics, hormonal, and immune factors all contribute to the development and progression of the disease. A number of endocrine disorders and metabolic syndromes are being studied for their potential role in the development of PAH. We report to you a case of a 32-year-old female with a rare presentation of a non-BMPR2 mutation heritable PAH complicated with empty sella syndrome and panhypopituitarism.

Granulomatous Mastitis With Breast Abscess Caused by Salmonella

Granulomatous mastitis (GM) is a rare disease that occurs in young premenopausal women, is mostly idiopathic, and is less likely to be caused by infection and trauma. It is also strongly associated with pregnancy, lactation, and hyperprolactinemia. GM superimposed by infection with abscess formation caused by Salmonella is extremely rare. Upon reviewing the literature, our case is considered to be the first reported case globally. Most breast abscesses are caused by Staphylococcus aureus.

Adrenal Insufficiency Associated With Empty Sella Syndrome and Steroid Malabsorption Complicated With Septic Shock Due to Post-transplant Pyelonephritis: A Case Report

Renal transplant recipients are immunocompromised and predisposed to develop hyponatremia because they are exposed to immunological, infectious, pharmacological, and oncologic disorders. A 61-year-old female renal transplant recipient was admitted with diarrhea, anorexia, and headache for about a week during the tapering of oral methylprednisolone for chronic renal allograft rejection. She also presented hyponatremia and was suspected to have secondary adrenal insufficiency based on a low plasma cortisol level of 1.9 μg/dL and a low adrenocorticotropic hormone level of 2.6 pg/mL. Brain magnetic resonance imaging to assess the hypothalamic-pituitary-adrenal axis revealed an empty sella. She also developed septic shock and disseminated intravascular coagulation due to post-transplant pyelonephritis. She had reduced urine output and underwent hemodialysis. Both plasma cortisol and adrenocorticotropic hormone levels were relatively low (5.2 μg/dL and 13.5 pg/mL, respectively), which also suggested adrenal insufficiency. She was treated with hormone replacement therapy and antibiotics, successfully recovered from septic shock, and was withdrawn from dialysis. In empty sella syndrome, the somatotropic and gonadotropic axis are the most affected, followed by the thyrotropic and corticotropic axis. She did not present these abnormalities, which may suggest that empty sella syndrome is a separate pathology, and the axis suppression had occurred due to long-term steroid treatment. Diarrhea due to cytomegalovirus colitis might have induced steroid malabsorption and manifested adrenal insufficiency. Secondary adrenal insufficiency should be investigated as a cause of hyponatremia. It should always be borne in mind that diarrhea during oral steroid treatment may cause adrenal insufficiency associated with steroid malabsorption.

A Case of Sheehan Syndrome Six Years Postpartum Presented With Adrenal Crisis and Complicated by Hypothyroidism and Massive Pericardial Effusion

Sheehan syndrome is often a sequela of massive postpartum hemorrhage in resource-poor healthcare settings where blood loss during delivery is often neglected. The diagnosis of this rare but fatal disease is often delayed because the symptoms are vague and the pituitary dysfunction is insidious in nature. We report the case of a 35-year-old multiparous female with anhedonia and raised serum transaminases. She presented with constitutional symptoms. Her last vaginal delivery, six years back, was the last obstetric event that yielded a stillbirth child. She had had amenorrhea since then. Upon further evaluation, she was found to have a massive pericardial effusion, hypopituitarism, and a partially empty sella. This case report highlights the uncharacteristic symptoms that a patient presents with which ultimately lead to delayed diagnosis. Early diagnosis can go miles in improving the quality of life of the patient besides saving the patient from an adrenal crisis.

The 1 μg Synacthen stimulation test in the diagnosis of secondary adrenal insufficiency in patients with Rathke's cleft cyst and empty sella syndrome

INTRODUCTION

Rathke's cleft cyst (RCC) and primary empty sella syndrome (PESS) are usually incidental findings on magnetic resonance imaging (MRI) scans. In most cases, these lesions do not cause mass effect symptoms and do not require surgical intervention. In patients with RCC or PESS, it is important to exclude secondary adrenal insufficiency (SAI), which may be a life-threatening condition.

MATERIAL AND METHODS

The incidence of SAI was assessed in patients with RCC or PESS detected by MRI, using the 1 μg Synacthen stimulation test. A total of 38 patients were analysed. Test results were linked to clinical symptoms and the type of cystic lesion.

RESULTS

Assuming that cortisol levels < 14.6 μg/dL in Synacthen test are the criterion of SAI diagnosis, SAI was diagnosed only in 2 patients (5%). Adopting the traditional criterion of cortisol levels < 18 μg/dL, SAI would be diagnosed in 7 patients (18.4 %). Dizziness (Chi2 = 3.89; p = 0.049) and apathy (Chi2 = 3.87; p = 0.049) were significantly more frequent in the PESS group than in the RCC group.

CONCLUSIONS

The incidence of SAI in the general patient population with empty sella syndrome and Rathke's cleft cysts is low. The 1 μg Synacthen test seems to be a valuable tool in the diagnosis of SAI among patients with RCC and PESS. Further studies are necessary to determine the sensitivity and specificity of the 1 μg Synacthen test with the standardization of test protocol and considering the cortisol level at the 20-minute timepoint. PESS patients report dizziness and apathy more frequently than RCC patients, which does not result from the disturbance of the hypothalamic-pituitary-adrenal axis, but probably from the different pathogenesis of these cystic lesions.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

EMPTY SELLA IN A PATIENT WITH CLINICAL AND BIOCHEMICAL DIAGNOSIS OF ACROMEGALY

BACKGROUND

Acromegaly is an acquired disorder related to excessive production of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Empty sella (ES) is an anatomical condition of sella turcica that is partially or completely filled with cerebrospinal fluid mainly due to intrasellar herniation of subarachnoid space. Here, we describe a patient who presented with clinical and biochemical features of acromegaly and who had an ES on pituitary magnetic resonance imaging (MRI).

CASE REPORT

A 73-year-old male patient was consulted in our clinic because of the acromegalic phenotype while planning for colorectal adenocarcinoma surgery. The patient noticed gradual enlarging of his hands, feet and nose for 30 years, but never consulted to any clinician for this reason. Serum GH was 20.6 ng/mL (normal <3 ng/mL) and IGF-1 was 531 ng/mL (normal, 69-200 ng/ml). An oral glucose tolerance test showed no suppression of GH values. T1-weighted MRI revealed an ES. 18F-FDG PET/CT and Ga-DOTATADE PET/CT did not show any finding consistent with ectopic GH secretion. Growth hormone releasing hormone (GHRH) was within the normal range (<100mg/dL). He was treated with long-acting octreotide 20 mg per 28 days. At the 6^th month of treatment, serum GH and IGF-1 levels were decreased to 5.45 ng/mL and 274 ng/mL, respectively.

CONCLUSION

The mechanism underlying the association of acromegaly and ES remains unclear. Apoplexy on existing pituitary adenoma and then formation of necrosis can proceed to ES. Since our patient did not have a history of pituitary apoplexy and we could not find any reason for secondary ES, we considered primary ES.

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.

Characteristics of Patients with Hypopituitarism having Onset Symptoms of Pseudo-Intestinal Obstruction: A Case Report

BACKGROUND

Gastrointestinal symptoms are often the first symptoms of hypopituitarism. However, pseudo-intestinal obstruction is not a common manifestation of hypopituitarism. Some patients presenting with gastrointestinal symptoms as their chief complaint were admitted to the Department of Gastroenterology and were accurately diagnosed with hypopituitarism at the Department of Endocrinology.

CASE SUMMARY

This case pertains to a 57-year-old man with poor appetite, fatigue, weakness, and recent onset recurring abdominal pain. An erect, abdominal X-ray indicated flatulence and gas-fluid levels in the midsection of the abdomen, and pseudo-intestinal obstruction was diagnosed. Subsequently, the patient was referred to the Department of Gastroenterology to identify the cause of the pseudo-intestinal obstruction. An examination of the digestive system did not reveal any abnormalities, but the patient developed hyponatremia and exhibited drowsiness. The patient was transferred to the Department of Endocrinology for further treatment. The patient was eventually diagnosed with hypopituitarism, caused by empty sella syndrome. The patient received prednisone and euthyrox replacement therapy, and pseudo-intestinal obstruction did not occur again.

CONCLUSION

In general, endocrine diseases, including hypopituitarism, hypothyroidism, and hyponatremia, should be considered for patients with pseudo-intestinal obstruction combined with hyponatremia and drowsiness, especially if the symptoms of the digestive system are not complicated and the drowsiness is obvious.

A case report of empty Sella syndrome secondary to Hantaan virus infection and review of the literature

RATIONALE

Bleeding in the anterior pituitary lobe leading to tissue necrosis occurs in the acute stage of severe clinical forms of hemorrhagic fever with renal syndrome (HFRS), while atrophy of the anterior pituitary lobe with diminution of the gland function occurs after the recovery stage. The relationship between Hantaan virus infection and empty Sella syndrome (ESS) has rarely been reported.

PATIENT CONCERNS

This patient was a 54-year-old previously healthy Chinese male. He presented with fever, headache, and backache with dizziness and oliguria. Physical examination was notable for hypotension and the signs of conjunctival suffusion. His platelets decreased, and his urine protein was positive. Hantaan virus IgM and virus RNA were positive.

DIAGNOSIS

He was diagnosed as having HFRS. In his diuretic phase, his 24-hour urine volume was maintained at 10,000 mL, and his blood pressure was higher for a week. Then, he was diagnosed as having ESS after a series of examinations.

INTERVENTIONS

Hormone replacement therapy was given to this patient after the diagnosis "ESS" was made.

OUTCOMES

The patient's symptoms improved, and he was discharged from the hospital soon after hormone replacement therapy.

LESSONS

Pituitary function examination and brain magnetic resonance imaging (MRI) need to be considered to scan for ESS and panhypopituitarism in the patients with HFRS accompanied by diabetes insipidus.

Isolated Adrenocorticotropic Hormone Deficiency Presenting with Severe Hyponatremia and Rhabdomyolysis: A Case Report and Literature Review

BACKGROUND Isolated adrenocorticotropic hormone deficiency (IAD) is a rare disorder characterized by central adrenal insufficiency (AI) but normal secretion of pituitary hormones other than adrenocorticotropic hormone. IAD usually presents with unspecific symptoms of AI, such as anorexia and fatigue, but some patients present with a variety of atypical manifestations. Rhabdomyolysis is a potentially life-threatening clinical syndrome caused by skeletal muscle injury with the release of muscle cell contents into the circulation. A wide variety of disorders can cause rhabdomyolysis. Herein, we report an unusual case of IAD presenting with hyponatremia and rhabdomyolysis. CASE REPORT A 67-year-old Japanese woman with a 2-month history of anorexia and fatigue was diagnosed with severe hyponatremia (serum sodium, 118 mEq/L) and rhabdomyolysis (serum creatine phosphokinase, 6968 IU/L), after 2 days of vomiting and muscle weakness. Physical and laboratory findings did not show dehydration or peripheral edema. Her rhabdomyolysis resolved with normalization of serum sodium levels during administration of sodium chloride. However, her anorexia and fatigue remained unresolved. After reducing the amount of sodium chloride administered, the patient still had hyponatremia. Detailed endocrinological examinations indicated IAD; her hyponatremia was associated with inappropriately high plasma arginine vasopressin levels. The patient received corticosteroid replacement therapy, which resolved her anorexia, fatigue, excessive arginine vasopressin, and hyponatremia. CONCLUSIONS This case highlights the importance of considering the possibility of central AI in patients with hyponatremia and excessive arginine vasopressin levels. In addition, rhabdomyolysis associated with hyponatremia can be an important manifestation of IAD.

Refractory Hypoglycemia and Seizures as the Initial Presenting Manifestation of Empty Sella Syndrome

An empty sella is reported to occur in 5.5%–23.5% of the population and is usually asymptomatic. It can be associated with endocrine disturbances. We report a 48-year-old woman who presented with refractory hypoglycemia, seizures, and shock that improved with levothyroxine, hydrocortisone, and octreotide. Investigations revealed central hypothyroidism, hypoprolactinemia, low gonadotropins, normal C-peptide and a primary empty sella. Case reports of Sheehan syndrome with or without empty sella causing hypoglycemia have been reported occasionally. Our patient had never become pregnant. She had experienced premature menopause and symptoms suggestive of hypothyroidism for many years (without treatment) before her emergency department admission for altered sensorium. 

Ectopic Acromegaly Arising from a Pituitary Adenoma within the Bony Intersphenoid Septum of a Patient with Empty Sella Syndrome

Objective

 To describe the work-up and treatment of rare ectopic acromegaly caused by a biopsy-proven somatotroph pituitary adenoma located within the bony intersphenoid septum of a patient with empty sella syndrome (ESS).

Methods

 We report the presentation, clinical course, diagnostic work-up, and lesion localization and treatment challenges encountered in a 55-year-old patient, with a brief review of relevant literature.

Results

 A 55-year-old African-American man presented with acromegaly and ESS. Attempts to definitively localize the causative tumor were unsuccessful, though petrosal sinus sampling supported central growth hormone production and imaging suggested bone-enclosed subsellar pituitary tissue. Endoscopic endonasal transphenoidal exploration was undertaken with resection of a somatotroph pituitary microadenoma, and subsequent clinical improvement and biochemical remission. Retrospective review revealed the patient's pituitary to have been located ectopically within a unique bony intersphenoid septum.

Conclusion

 This report describes the first known case of an ectopic pituitary adenoma located within the midline bony intersphenoid septum, which we postulate to have resulted from anomalous embryological pituitary migration. Intra-intersphenoid septal tumors should be considered in cases of apparent central acromegaly with ESS or absence of tumor tissue within the paranasal sinuses or other peripheral locations.

Indexing

 Acromegaly, ESS, pituitary adenoma, sphenoid sinus septum.

Effect of primary empty sella syndrome on pituitary surgery for Cushing's disease

OBJECT

Primary empty sella syndrome (ESS) results from herniation of arachnoid mater into the pituitary fossa. It has been suggested to have a negative effect on pituitary surgery; however, outcomes in this cohort have not been defined. This study was performed to determine the effect of ESS on immediate and long-term biochemical outcome after pituitary surgery for Cushing's disease (CD).

METHODS

Using a matched cohort study design, the authors followed patients treated with pituitary surgery for CD with and without ESS. Complete ESS was defined as pituitary gland height ≤ 2 mm, whereas partial ESS was defined as pituitary gland height > 2 mm but less than three-quarters of the total sellar depth. The primary end points were immediate and long-term biochemical outcome. Cerebrospinal fluid leaks were recorded as a secondary end point.

RESULTS

Seventy-eight patients with CD and primary ESS were identified and matched with 78 patients with CD without ESS. After surgical management, immediate biochemical remission was achieved in 69 patients (88%) with ESS and 75 controls (96%, p = 0.10). Long-term remission was achieved in most patients in both groups (5-year cure: 85% vs 92%, p = 0.10). Among patients with ESS, the presence of complete ESS predicted a worse long-term outcome (p = 0.04). Intraoperative CSF leaks were significantly more frequent with ESS (54% vs 24%, p < 0.001), and despite sellar floor repair, the rate of postoperative CSF leaks was also increased (6% vs 3%, p = 0.27).

CONCLUSIONS

Biochemical outcome after pituitary surgery for CD was worse in patients with complete ESS, and the risk of a CSF leak was increased with both partial and complete ESS. However, as outcome remains superior to those following alternative therapies and the biology of these tumors is unchanged in the setting of ESS, pituitary surgery should remain the initial treatment of choice.

Osteoporotic fractures and persistent non-fusion of the hand epiphyses caused by empty sella syndrome in an adult: a case report

We report a case of primary empty sella syndrome (ESS) resulting in osteoporotic fractures and persistent non-fusion of the hand epiphyses, and discuss the potential pathogenesis of this disease. A 41-year-old man presented with pain in the right hand and back after a fall. X-radiographs revealed persistent epiphyses and severe osteoporosis. Serum phosphorus and prolactin levels were above normal levels, and free triiodothyronine, free thyroxine and testosterone levels were below normal limits. Magnetic resonance imaging of the head revealed empty sella. A lumbar bone mineral density examination indicated severe osteoporosis. ESS caused a systemic hormone disorder in this patient, resulting in osteoporotic fractures and persistent non-fusion of the hand epiphyses. Possible causes of this anomaly are chronic or congenital abnormities of the pituitary gland.

Pre-existing undiagnosed central diabetes insipidus unmasked after renal transplantation

Central diabetes insipidus (CDI) is characterized clinically by the presence of polyuria with the subsequent development of volume depletion and hypernatremia. In patients with dialysis-dependent end-stage renal disease (ESRD), neither of these findings can be expressed due to the absence of renal function. A 59-year-old woman with anuric ESRD of unknown etiology had been on peritoneal dialysis for 8 years prior to receiving a cadaveric allograft. Postoperatively, she developed persistent polyuria and hypernatremia. A desmopressin test confirmed the diagnosis of CDI. A magnetic resonance imaging (MRI) of the brain revealed an empty sella turcica. Maintenance therapy with intranasal desmopressin resulted in complete resolution of the polyuria. At 6-month follow-up on daily desmopressin, the patient maintains normal serum sodium levels and stable allograft function. This is a unique case of CDI from empty sella syndrome (ESS) that was unmasked only after the restoration of normal renal function following successful renal transplantation.

Usefulness of magnetic resonance findings of the hypothalamic-pituitary region in the management of short children with growth hormone deficiency: evidence from a longitudinal study

PURPOSE

The purpose of this study is to assess the relationship between magnetic resonance images (MRI) of the hypothalamic-pituitary (H-P) region and response to recombinant human growth hormone (rhGH) treatment in short children with growth hormone deficiency, basing on changes of auxologic parameters, as well as to answer the question if MRI may serve for selecting and monitoring the rhGH responders.

PATIENTS AND METHODS

The study group comprised 85 children treated with rhGH, aged 7.3-18.7 years, followed for the mean period of 3.2 years (range, 2.1-9.5 years). Auxologic parameters (height deficit hSDS, deviation from the mid-parental height hSDS-mpSDS, bone delay index bone age/chronological age ratio (BA/CA)) were assessed before, during and at the end of rhGH treatment; growth velocity was calculated before and during rhGH therapy. Parameters were correlated with the MRI of the H-P region.

RESULTS

Structural anomalies of the H-P region were found in 22 (25.9%) children: empty sella syndrome (ESS) in 12 (14.1%) patients, ectopic posterior pituitary (EPP) in ten (11.8%). Patients' height deficit and their deviation from parental height before rhGH therapy was significantly greater in the EPP group (median hSDS = -3.8; hSDS-mpSDS = -2.5), bone age delay was the greatest in the ESS group (median BA/CA = 0.69), after therapy - in the EPP group (median BA/CA = 0.82). Growth velocity improved in the first year of the rhGH therapy in all groups; however, the most significant acceleration was observed in the EPP group (median delta hSDS = 0.9), then stabilised and was comparable in all groups.

CONCLUSIONS

MRI may be helpful in predicting response to the rhGH treatment, providing midline abnormalities are taken into account.

Empty sella syndrome associated with central nervous system cysticercosis

A 55-year-old woman presented with severe recurrent headache accompanied by dizziness. The brain CT scan showed multiple low-density cystic lesions in the suprasellar and left sylvian cisternae with total empty sell syndrome. The communication between the cisternae and the suprasellar cyst was not verified on the metrizamide CT scan. Treatment with praziquantel resulted in headache inilially and a rise in specific IgG.