Endocrine function in human obesity

Context: The term primary empty sella (PES) refers to a number of endocrine and/or neurological disturbances that may be caused by the herniation of subarachnoid space within the sella. Setting: The records of all patients with a diagnosis of empty sella between 1985 and 2002 seen at the Catholic University of Rome and University of Brescia were examined retrospectively. Patients: We have observed 171 female and 42 male patients affected by PES (over 4:1 sex ratio). The mean age at diagnosis in our subjects was 51.8 ± 2.1 yr. Mean body mass index was 27.3 ± 3.5 kg/m2. Main Outcome Measure: All the patients have been analyzed first either with sellar computed tomography scan or magnetic resonance imaging. All patients underwent neurological, ophthalmological, and baseline endocrine evaluation (appropriate stimulation tests were performed when hypopituitarism was suspected). Results: In the overall population, 40 of 213 patients had documented endocrine abnormalities, specifically 31 females and nine males....

Primary empty sella.

BACKGROUND AND PURPOSE: The sphenoid sinus is rarely implicated as a site of spontaneous CSF fistula. We undertook this study to evaluate the potential etiopathogenesis of spontaneous CSF fistula involving the sphenoid sinus and to review the imaging findings. METHODS: We retrospectively reviewed the imaging findings of 145 cases of CSF fistula from our departmental archives (August 1995 through August 1998). Fifteen (10%) patients had CSF fistulas involving the sphenoid sinus. Eleven (7%) patients had spontaneous CSF fistulas, whereas in four patients, the CSF fistulas in the sphenoid sinus were related to trauma. Of the 11 patients, nine underwent only plain high-resolution CT and MR cisternography. One patient additionally underwent contrast-enhanced CT cisternography, and one other patient underwent MR cisternography only. For each patient, the CSF fistula site was surgically confirmed. The MR imaging technique included T1-weighted and fast spin-echo T2-weighted 3-mm-thick coronal sequences obtained with the patient in the supine position. The plain high-resolution CT study included 3-mm-thick, and sometimes 1- to 1.5-mm-thick, coronal sections obtained with the patient in the prone position. Similar sections were obtained after injecting nonionic contrast material intrathecally via lumbar puncture for the CT cisternographic study. We evaluated each of the 11 patients for the exact site of CSF leak in the sphenoid sinus. We also determined the presence of pneumatization of lateral recess of the sphenoid sinus, orientation of the lateral wall of the sphenoid sinus, presence of arachnoid pits, presence of brain tissue herniation, and presence of empty sella in each of these patients. RESULTS: The exact sites of the CSF fistulas were documented for all 11 patients by using plain high-resolution CT, MR cisternography, or CT cisternography. In nine (82%) patients, the sites of the CSF fistulas were at the junction of the anterior portion of the lateral wall of the sphenoid sinus and the floor of the middle cranial fossa. In the remaining two (18%) patients, the sites of the CSF fistulas were along the midportion of the lateral wall of the sphenoid sinus. Of these 11 patients, one had bilateral sites of the CSF fistula at the junction of the anterior portion of the lateral wall of the sphenoid sinus with the floor of the middle cranial fossa. In nine (82%) patients, the presence of brain tissue herniation was revealed, and this finding was best shown by MR cisternography. Ten (91%) patients had extensive pneumatization of the lateral recess of the sphenoid sinus, with an equal number having outward concave orientation of the inferior portion of the lateral wall of the sphenoid sinus. In seven (63%) patients, the presence of arachnoid pits, predominantly along the anteromedial aspect of the middle cranial fossa, was shown. In seven (63%) patients, empty sella was shown. For comparison, we reviewed the CT studies of the paranasal sinuses in 100 age-matched control subjects from a normal population. Twenty-three had extensive lateral pneumatization of the sphenoid sinus along with outward concavity of the inferior portion of the lateral wall. None of these 23 patients had arachnoid pits. CONCLUSION: The sphenoid sinus, when implicated as a site of spontaneous CSF leak, yields a multitude of imaging findings. These are extensive pneumatization of the lateral recess of the sphenoid sinus, outward concave orientation of the inferior portion of the lateral wall of the sphenoid sinus, arachnoid pits, and empty sella. Considering the normative data, we speculate that this constellation of findings could play a role in the etiopathogenesis of spontaneous sphenoid sinus fistulas. Our findings also show the efficacy of noninvasive imaging techniques, such as plain high-resolution CT and MR cisternography, in the evaluation of sphenoid sinus CSF leak. Our data also suggest that spontaneous sphenoid sinus CSF leak is not an uncommon occurrence.

http://www.ajnr.org/content/ajnr/21/2/337.full.pdf

A Retrospective Analysis of Spontaneous Sphenoid Sinus Fistula: MR and CT Findings

Authors analyzed retrospectively the incidence of pituitary apoplexy in a series of 799 pituitary adenomas with respect to the long term follow-up of the patients. Focal vascular abnormalities in histological specimens of tumours, regarded as morphological suggestion of past apoplexy (haemorrhage, ischaemic infarction or necrosis), were established in 113 out of 783 surgical cases (14.4%). Acute clinical onset, justifying the clinical diagnosis of pituitary apoplexy, occurred in 39 patients only (5% of the whole series), 19 of them were subjected to urgent surgical decompression due to severe neurological deficit. The haemorrhagic character of apoplexy was established in most cases requiring immediate surgery. The detailed clinical picture of this condition and its management are discussed with respect to the long term prognosis. On this basis the authors suggest the necessity of surgical treatment in every case of pituitary apoplexy, taking into account not only neurological recovery, but also endocrine and oncological aspects of the disease. The observation that pituitary apoplexy may be a "marker" of tumour invasiveness (even in small, "enclosed" adenomas) is highlighted.

Pituitary apoplexy: endocrine, surgical and oncological emergency. Incidence, clinical course and treatment with reference to 799 cases of pituitary adenomas.

Adrenal crisis represents the major endocrine emergency with a fatal outcome if not properly recognized and correctly treated. It can present as the first manifestation of acute or chronic primary adrenal failure. Secondary adrenal insufficiency with usually less dramatic manifestations can cause mental disturbances, electrolyte or metabolic disorders severe enough to warrant prompt correction and therapeutic intervention. This is particularly true in cases of abrupt cessation of steroid treatment, pituitary apoplexy and Sheehan's syndrome. Hyperfunction of the adrenal cortex, be it hypercorticism or hypermineralocorticism, can also require rapid treatment of electrolyte disorders and hypertension. The symptoms and differential diagnosis of these entities are described as well as their proper treatment. In order to confirm later the diagnosis, the need to secure biological samples for hormone determination before starting treatment is emphasized.

3 Disorders of the adrenal cortex

The primary empty sella syndrome: Analysis of the clinical characteristics, radiographic features, pituitary function and cerebrospinal fluid adenohypophysial hormone concentrations

Large, adrenocorticotrophic hormone-secreting pituitary tumors (Nelson's syndrome) developed in four of 12 patients treated with a bilateral adrenalectomy for Cushing's disease. Two of the patients with Nelson's syndrome suffered spontaneous pituitary tumor infarctions. One patient improved under close observation and subsequent radiation therapy, although she ultimately died from her locally invasive tumor. The condition of the other patient—which had stabilized—appeared to be worsened by surgical intervention. The high incidence of these tumors after bilateral adrenalectomy, their large and aggressive nature, and their apparent propensity to undergo spontaneous infarction supports the position that initial therapy for Cushing's disease should be directed to the pituitary gland. (Arch Intern Med139:340-342, 1979)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=intemed&articleId=589185&pdfFileName=archinte_139_3_021.pdf

Nelson's Syndrome and Spontaneous Pituitary Tumor Infarction

Twelve cases of the primary empty seiia syndrome were analyzed in regard to clinical findings, roentgenographic features, pituitary function and cerebrospinai fluid adenohypophysiai hormone concentration. The findings were compared with those in 247 cases of the primary empty seiia syndrome reviewed from the literature in order to determine the major characteristics of this disorder. The majority of patients are obese, multiparous women with normal pituitary reserve, normal visual fields and undetectable adenohypophysiai hormone concentrations in cerebrospinai fluid. in addition, occasional patients will have hypertension, pseudotumor cerebri and cerebrospinai fluid rhinorrhea. Patients who present with the typical features of the primary empty seiia syndrome should be evaluated periodictiiiy with pituitary function testing, visual field examinations and cerebrospinai fluid adenohypophysiai hormone determinations. if these parameters remain normal during careful follow-up studies, the patient is likely to have an empty seiia, and pneumoencephaiographic and angiographic studies can be avoided.

https://www.amjmed.com/article/0002-9343(77)90420-X/pdf

Charles W. Kerber

Papers

The primary empty sella syndrome: Analysis of the clinical characteristics, radiographic features, pituitary function and cerebrospinal fluid adenohypophysial hormone concentrations

Nelson's Syndrome and Spontaneous Pituitary Tumor Infarction

Analysis of the Clinical Characteristics, Radiographic Features, Pituitary Function and Cerebrospinal Fluid Adenohypophysial Hormone Concentrations