Magnetic resonance imaging finding of empty sella in obesity related idiopathic intracranial hypertension is associated with enlarged sella turcica.

INTRODUCTION: Empty sella in MRI is an important finding associated with idiopathic intracranial hypertension (IIH). This study assesses the sensitivity and reproducibility of several morphological measures of the sella and pituitary gland to indentify the measure that best differentiates IIH from controls. Additionally, the study assesses reversal in gland compression following treatment. METHODS: Sagittal 3D-T1W sequence with 1 mm isotropic resolution was obtained from ten newly diagnosed IIH patients and 11 matched healthy controls. Follow-up MRI scans were obtained from eight patients at 1-week post-lumbar puncture and acetazolamide treatment. 1D and 2D measures of absolute and normalized heights and cross-sectional areas of the gland and sella were obtained to identify the measure that best differentiates IIH patients and controls. RESULTS: Overall area-based measurements had higher sensitivity than length with p < 0.0001 for sella area compared with p = 0.004 for normalized gland height. The gland cross-sectional areas were similar in both cohorts (p = 0.557), while the sella area was significantly larger in IIH, 200 ± 24 versus 124 ± 25 mm(2), with the highest sensitivity and specificity, 100% and 90.9%, respectively. Absolute gland area was the most sensitive measure for assessing post treatment changes, with 100% sensitivity and 50 % specificity. Average post-treatment gland area was 18% larger (p = 0.016). Yet, all eight patients remained within the empty sella range based on a normalized gland area threshold of 0.41. CONCLUSIONS: Sellar area is larger in IIH, and it demonstrated highest sensitivity for differentiating IIH from control subjects, while absolute gland area was more sensitive for detecting post treatment changes.

Ontogenetic changes of craniofacial complex in Turner syndrome patients treated with growth hormone.

OBJECTIVE: The present study assessed changes of craniofacial complex in Turner syndrome (TS) patients treated with growth hormone (GH) during development. The objective was to examine the growth rate and pattern of craniofacial structures and to establish effects of GH on craniofacial development. MATERIALS AND METHODS: The study population consisted of 15 TS patients treated with GH aged 5-18.5 years (13.3 ± 4.4) and corresponding control group of 45 females aged 6.8-18.7 (11.4 ± 2.6). According to the stage of cervical vertebral maturation, subjects were categorized into pre-growth (5 TS and 15 controls) and growth (10 TS and 30 controls) subgroups. The cephalometric analysis comprised angular and linear variables, measured on lateral cephalometric radiographs. RESULTS: The mandibular corpus/anterior cranial base ratio increased significantly only in controls during development. In growth period, ramus/corpus ratio was significantly larger in TS group. SNA and SNB angles were significantly smaller in TS growth subgroup compared to corresponding controls. Among other variables, no statistically significant differences were revealed. CONCLUSIONS: In TS patients treated with GH, growth capacities of cranial base and maxilla are adequate which can be attributed to GH treatment. Shape of mandible is altered due to decreased growth of corpus and overdeveloped ramus. Both maxillary and mandibular retrognathism are becoming more expressed during development. CLINICAL RELEVANCE: Favorable influence of GH on craniofacial complex growth rate and altered growth pattern revealed in this study should be considered while planning both orthodontic treatment and retention.

Brain and optic chiasmal herniations into sella after cabergoline therapy of giant prolactinoma.

Optic chiasmal herniation following dopamine agonist therapy is a rare complication in patients with giant prolactinomas. But there are a few case reports of brain and chiasmal herniation following medical therapy in such cases. We report a young man who developed secondary visual loss and seizures after 6 months of medical treatment with cabergoline for giant prolactinoma. Magnetic resonance imaging of hypothalamic pituitary region revealed optic chiasmal and frontal lobe herniation into sella. There was marginal improvement in his vision after cabergoline dose reduction. The present case report highlights frontal lobe herniation in conjunction with optic chiasmal herniation as a very rare complication of medical therapy of giant prolactinoma. Different treatment options of this condition are being discussed.

Endoscopic ultrasound imaging with high flow mode for endonasal transsphenoidal pituitary surgery.

Intraoperative ultrasound during transsphenoidal surgery (TSS) for pituitary tumors has been reported. In reports of endonasal ultrasound (US), Doppler US vessel images were informative and effective in endoscopic TSS. We performed endoscopic US imaging with high flow mode, which is a novel technology, to visualize small vessels during endonasal endoscopic TSS. Six patients (five with pituitary adenomas and one with Rathoke's cleft cyst) underwent endoscopic US-assisted TSS. A small endoscopic US probe (Olympus, BF-UC260FW; diameter, 6.9 mm) was inserted transsphenoidally to the sellar floor and into the sella turcica, and endoscopic US monitoring was performed. By rotating the endoscopic US probe, the internal carotid artery, anterior cerebral artery, middle cerebral artery, various small vessels, optic nerve, and residual tumor were clearly visualized on the endoscopic US images. Real-time animated vessel images around the tumor could be generated when needed during TSS. The tumors were removed without leakage of cerebrospinal fluid in the six patients, and their visual acuity was restored. Endoscopic US with high flow mode can visualize not only main cerebral arteries but also intracranial small vessels on B-mode US images. Pituitary tumors were clearly recognized and removed safely and precisely by monitoring the cerebral artery and its small branches as landmarks.

Aspergillus sellar abscess: case report and review of the literature.

Aspergillus sellar abscess is a very rare form of fungal infections of the central nervous system (CNS). In this report, we describe the successful treatment of a patient with aspergillus sellar abscess. A 65-year-old woman presented with headache, nasal discharge and decreased visual acuity. The diagnosis of sellar mass was made on the basis of magnetic resonance imaging (MRI) examination. The computed tomography (CT) scan revealed sellar enlargement and sellar floor bony destruction. After hospitalization the patient underwent transsphenoidal surgery. Histopathological examination of the sellar mass revealed aspergillosis. Postoperatively, amphotericine-B and itraconazole therapy was started. During a six-month follow-up, the patient's headache and inertia disappeared, visual acuity improved. Aspergillus sellar abscess must be considered in the differential diagnosis of a sellar mass. The correct diagnosis of pituitary aspergillosis can only be achieved by histopathological examination. Surgical intervention and antifungal therapy should be considered the optimal treatment.

Effects of long-term treatment with thyroxine on pituitary TSH secretion and heart action in patients with hypothyroidism.

The effects of thyroxine (T4) treatment on pituitary thyrotroph cells and on the heart were studied in 68 female patients with hypothyroidism. During the initial 12 months of T4 treatment, relatively small doses of T4 (1.3 micrograms/kg) normalized serum T4, triiodothyronine (T3), TSH and lipid concentrations in mild hypothyroidism, while moderate doses of T4 (1.7-2.0 micrograms/kg) normalized serum T4, T3 and lipid concentrations but not serum TSH levels or the volume of sella turcica in moderate and severe hypothyroidism; however, serum TSH levels and the volume of sella turcica returned to normal with continuation of these doses of T4. Systolic time intervals (ET/PEP) can discriminate between euthyroid and hyperthyroid states and agree well with serum TSH levels. However, ET/PEP was unequivocally elevated in about 40% of treated hypothyroid patients with normal serum T3, T4 and TSH levels which had been maintained over 48-54 months. Since the reciprocal relationship between free T4 and TSH levels was maintained in all treated patients, elevated ET/PEP with normal TSH levels indicates that the heart is more sensitive to thyroid hormones than the pituitary thyrotroph in 40% of treated hypothyroid patients. During T4 treatment in patients with hypothyroidism, ET/PEP should be followed and T4 doses adjusted to maintain normal ET/PEP rather than normal serum TSH levels, especially in older patients in whom T4 may aggravate angina pectoris or provoke myocardial infarction.

Treatment of diffuse metastatic cancer pain by instillation of alcohol into the sella turcica.

The technique of "chemical hypophysectomy" was modified for the management of pain due to metastatic cancer. Using stereotaxic control, a needle is introduced via the nose into the sella turcica. Absolute alcohol is then injected into the pituitary. Of 13 patients who had severe uncontrollable pain, 11 obtained marked symptomatic relief. The longest follow-up period to date is seven months, with results persisting. Sequelae are those associated with destruction of the pituitary gland, the most significant being diabetes insipidus. Several cerebrospinal fluid leaks prompted us routinely to instill alpha-ethyl cyanoacrylate to seal the sella floor. Three patients had slight extraocular nerve palsies. There was no death related to the procedure.

Glucagon-initiated human growth hormone release: a comparative study.

Human growth hormone (HGH) responses in 20 healthy adults to subcutaneous glucagon, arginine infusion and tolbutamide and insulin hypoglycemia were compared. HGH rose in all four tests. HGH response to glucagon was also studied in 49 patients with suspected pituitary insufficiency, of whom 25 also later received an arginine infusion; an abnormal response to glucagon was the most frequent functional abnormality and often HGH was the only anterior pituitary hormone of which a deficiency was detectable. In seven subjects (two healthy controls and five patients with suspected hypopituitarism) there was a subnormal HGH response to arginine but a normal response to glucagon. It is concluded that glucagon is a simple and effective stimulus to HGH release, equal or superior to arginine, tolbutamide and insulin, and is an important test of anterior pituitary function.