Primary empty sella

Introduction: The term primary empty sella (PES) makes reference to the herniation of the subarachnoid space within the sella turcica in patients with no history of pituitary tumor, surgery or radiotherapy. Materials and Methods: We studied 36 patients; 27 females and 9 males. The mean age at diagnosis was 50, 4 years [21-80 years]. Most diagnoses were made by magnetic resonance imaging (n = 32). The anterior pituitary function was evaluated by basal hormonal measurements. Then, we had compared two groups of patients: G1(n=17), who had a pituitary disorder, and G2 (n=10), patients without hormonal disease, in order to determine risk factors for endocrine dysregulation in PES. Results: The reasons for ordering pituitary scans were: headaches (65%), visual disturbances (32%) and neurological symptoms in 8% of cases. Sixty-six point five per cent of women were multiparous. Diabetes, obesity and hypertension were found in 19.45 %, 11 % and 19.45 % of the studied population respectively. Hyperprolactinemia was present in 17.24 % of patients. Fifty-five percent of our patients had some degree of hypopituitarism. We didn’t find any correlation in our study, between pituitary insufficiency and age, gender, weight, parity nor post-partum hemorrhage. Failure of lactation was significantly associated with a hormonal disorder. On the other hand, headache was negatively correlated with hormonal effects in PES. Conclusion: PES was most commonly found in middle-aged multiparous women. In most patients, PES is a heterogeneous condition that ranges from hypopituitarism to various degrees of isolated GH deficiency, and which needs careful endocrine assessment, treatment and follow-up.

Disclosure: D. Fawcett: None. S. Ceballos: None. C. Livasky: None. Introduction: Empty sella is a pituitary disorder characterized by the herniation of the subarachnoid space within the sella turcica. It can be further classified as primary empty sella (PES), considered an idiopathic disease or secondary empty sella (SES) which may result after pituitary tumor treatment, spontaneous necrosis, infection, autoimmune disease or brain trauma. Case Description: 47-year-old female with no medical history, who presented to emergency due to a 2-week history of fatigue associated with persistent heart pounding sensation and intermittent holocranial headache. On admission, the patient had sinus tachycardia with a normal blood pressure, and a non-focal neurologic exam. Her initial labs were significant for elevated lactic acid and low TSH. Initially a hyperthyroid etiology was considered, however, thyroid panel obtained on admission showed low T4 level. On further interrogation patient recalled a recent motor vehicle accident (MVA) a month prior to symptoms developing, without medical evaluation at the time. Brain MRI was completed as part of a central etiology work up demonstrating an empty sella with enlargement of the sella turcica measuring 1.6 cm. No contrast enhancing lesions were seen. Endocrinologic work up was consistent with a secondary adrenal insufficiency. Patient was discharged with hormonal thyroid and hydrocortisone supplementation. Discussion: Empty sella is a pituitary disorder in which a herniation of the subarachnoid space within the sella turcica occurs. There are two types: Primary empty sella (PES) which is considered idiopathic and is seen in patients with no history of previous pituitary pathology, and Secondary empty sella (SES) which may result after pituitary tumor treatment such as surgery or radiation, spontaneous necrosis, infection, autoimmune disease or brain trauma. The patient we presented did not have medical history consistent with autoimmune diseases or prior procedures. However, she did report an MVA with head trauma, that did not receive medical attention with subsequent development of headache and rest of previously described symptoms, highly concerning for a possible traumatic etiology. A high level of suspicion is required for diagnosis, particularly in patients with unspecific symptoms in order to improve patient’s prognosis. Presentation: 6/1/2024

Background: Sella turcica volumes vary greatly among patients both with and without pituitary dysfunction. We aim to investigate differences in sella turcica volumes and pituitary hormone levels among patients with primary empty sella (PES), sheehan syndrome (SS) and healthy individuals. Material and methods: We performed a retrospective case-control study of both the sella turcica volume and pituitary hormone levels of 75 female patients. These patients were divided into three groups: those with PES group, SS group and those with no known pituitary dysfunction. Results: We demonstrated that sella turcica volumes were measured as 895.6±330.6 mm3, 125.8±50.8 mm3 and 679.5±129.5 mm3 in PES group, SS group and healthy groups respectively. There was statisticaly difference between PES group and healthy group. Additionaly, SS group had statisticaly lower sella turcica volume than healthy group. PES group had statisticaly lower adrenocorticotropic hormone, cortisol, free T4, prolactin and insulin like growth factor-1 levels than healthy group. All of the SS group had panhypopituitarism. Conclusion: Enlarged sella turcica volume may be a risk factor for primary empty sella syndrome and primary empty sella related low hormone levels. Furthermore, we also demonstrate that smaller sella turcica volume may be a risk factor for developing Sheehan Syndrome. As such, we propose that sella volume may therefore be used as a predictor for devoloping pituitary hormone deficiencies in the future. Further clinical studies are required to better understand the relationship between sella turcica volume and pituitary hormone levels.

A 61-year-old woman under treatment with oral medroxyprogesterone acetate following surgery for breast cancer developed diplopia and papilledema due to raised intracranial pressure (ICP). Radiological studies disclosed an empty sella turcica, a dural arteriovenous malformation (AVM), and superior sagittal sinus thrombosis. The sinus thrombosis was considered to have been a side effect of the medroxyprogesterone acetate medication. The association between a primary empty sella and raised ICP is briefly discussed, along with the cause-and-effect relationship between a dural AVM and venous sinus thrombosis.

Background: In patients with secondary empty sella syndrome (ESS), optic nerve herniation into the sella turcica is caused by shrinkage of the mass lesion at the sella turcica, resulting in visual disturbance. ESS is often surgically treated using chiasmapexy. Here, we report the first case of spontaneous improvement in a patient with ESS.Case Description: A 69-year-old woman presented with a month-long history of visual disturbance in the right eye, poor visual acuity, and quadrantanopia in her upper temporal visual field. Magnetic resonance (MR) imaging showed herniation of her right optic nerve and gyrus rectus into the sella turcica. The visual disturbance gradually improved, and the patient’s vision became almost normal after a month without any treatment. On repeated MR imaging, it was observed that the herniation of the right optic nerve and gyrus rectus disappeared due to an intrasellar cyst re-expansion. The secondary ESS caused by the shrinkage of the intrasellar cyst resulted in the visual disturbance and re-expansion of the cyst resulted in spontaneous improvement of symptoms. The visual disturbance did not recur for a year.Conclusion: Patients with secondary ESS without severe symptoms may be followed up conservatively. However, surgical treatment should be applied if symptoms deteriorate or do not improve.

Aims: To determine the frequency and features of neuro-ophthalmological manifestations in neurologically symptomatic HIV infected patients and to assess whether or not the visual evoked potential (VEP) features in these...

The advantages of a rhinoseptal approach in the neurosurgical management of pituitary tumours are now well accepted. It was its harmlessness, rapidity and selectivity towards pituitary tissue which led us to choose it instead of any other one. This trans-sphenoidal approach can also be used for several non-pituitary tumours providing that they are also in relation to the sella. The origin of these tumours may thus be intrasellar, suprasellar, infrasellar or even lateral to the sella. Schoffer (1907) tapped a cystic craniopharyngioma by endonasal puncture and Halstead (6) (1909) performed the first trans-sphenoidal approach to a dysembryoplastic tumour. From 1975 to 1980 we operated on 279 pituitary adenomas by the trans-sphenoidal approach. During the same period, the same technique was used for 27 non-pituitary tumours of the sella turcica area (Table 1). Primary or secondary empty sella, benign purely intrasellar cysts and total hypophysectomy for metastatic breast carcinoma were excluded from this series. The 27 cases are divided into: 11 craniopharyngiomas, three chordomas, one chondroma, two dermoid cysts, seven sphenoidal tumours, two giant arachnoidal cysts and one glioma of the suprasellar area invading the skull base.

Aim: The combination of mechanical and drug procedures for the induction of labour seems to be beneficial. Accordingly, the normal procedure in clinical routine has been changed and induction of labour by means of a balloon catheter has been implemented. The aim of this study was to find out if this procedural change has resulted in a more effective induction of labour. Materials and Method: In this historical cohort study 230 inductions of labour at term in the year 2012 were compared with 291 inductions of labour in the year 2013, all at the University of Erlangen Perinatal Centre. Exclusion criteria were, among others, a multiple pregnancy, a premature rupture of membranes and a prior Caesarean section. In 2012 births were induced solely by use of the drugs dinoprostone and misoprostol, in 2013 not only with misoprostol but also mainly by use of a balloon catheter. The primary target parameter was the rate of failed labour inductions, defined as "no birth within 72 hours". Results: Altogether 521 inductions of labour were analysed. The rate of failed inductions of labour could be reduced by the changes in induction method (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204). Furthermore, the rate of primary Caesarean sections due to failed induction of labour (5.7 vs. 1.4 %, p = 0.0064), that of the observation of green amniotic fluid (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204) and of infantile infections (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204) were all reduced as well. Conclusion: The routine use of a balloon catheter for induction of labour has markedly improved the procedure. There were fewer failed labour inductions and fewer Caesarean sections due to failed induction of labour.

We experienced a case of delayed postoperative CSF rhinorrhea after the removal of a huge falx meningioma by the parieto-occipital interhemispheric approach. Retrograde review of the MRI revealed empty sella and subsequent Isovist CT cisternography disclosed the site of leakage, which was managed by a trans-sphenoidal approach. In order to avoid such cases we have made an analysis of brain MRIs to assist in detecting secondary empty sella syndromes. The authors retrospectively reviewed the preoperative MRIs of 53 cases of large brain tumors regardless of pathology, exempting pituitary tumors. Retrospective analysis of empty sella and review of brain MRI was done. The pituitary fossa was enlarged and filled partially or fully with CSF. Empty sella was evident in 60.3% of cases (32/53) and negative in 39.7% of cases (21/53). The incidence of secondary empty sella by pathology was as follows: (1) 20 out of 24 cases (83.3%) in meningiomas excluding 4 cases where the tumor had invaded the pituitary fossa (out of total 28 cases); (2) 55.6% (5/9 cases) in gliomas; (3) 0 cases out of 1 case in ganglioma; (4) 2/3 cases in hemangioblastomas; (5) 1/3 cases in acoustic schwannoma; (6) 2/2 cases in NF2; (7) 1/1 case of hemangiopericytoma; (8) 0/1 case lymphoma; (9) 1/2 cases lymphoma; (10) 0/1 case of PNET; (11) 0/1 case in AT & RT. Increased ICP attributed to long-standing, relatively large or huge benign tumor, causes compression of the CSF pathway, resulting in the herniation of the basal cisternal arachnoid membrane through a weakening in the diaphragm sellae into the pituitary fossa. This is generally regarded as the pathogenesis of secondary empty sella syndrome. The analysis showed that relatively slow-growing meningiomas with the exception of cavernous sinus, tuberculum sella, and clinoidal meningioma that directly invaded the pituitary fossa had a high incidence of secondary empty sella (83.3%), while rapid-growing glial tumors whose pathomechanism is invasion rather than ICP elevation showed lower incidence (55.6%). The cases of other pathologies were too few to analyze their respective incidences. Careful review of brain MRI with periodic follow-up is necessary for the detection of secondary empty sella in patients with brain tumor. In patients with confirmed empty sella, follow-up is mandatory because management of hypopituitarism, CSF rhinorrhea, visual disturbance, and increased ICP is necessary. Further accumulation of cases and analysis is required.

The determinants of Queensland's rising caesarean section (CS) rate remain poorly understood because of the historical absence of standard classification methods. We applied the Robson Ten Group Classification System (RTGCS) to population-based data to identify the main contributors to Queensland's rising CS rate. The RTGCS was applied retrospectively to the Queensland Perinatal Data Collection. CS rates were described for all ten RTGCS groups using data from 2006. Trends were evaluated using data for the years 1997-2006. Public and private sector patients were evaluated separately. In Queensland, in 2006, CS rates were 26.9 and 48.0% among public and private sector patients, respectively. Multiparous women with a previous caesarean birth (Group 5) made the greatest contribution to the CS rate in both sectors, followed by nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2) and nulliparous women in spontaneous labour (Group 1). CS rates have risen in all RTGCS groups between 1997 and 2006. The trend was pronounced among multiparous women with a previous caesarean delivery (Group 5), among women with multiple pregnancies (Group 8) and among nulliparous women who had labour induced or were delivered by CS prior to the onset of labour (Group 2). The CS rate in Queensland in 2006 was higher than in any other Australian state. The increase in Queensland's CS rates can be attributed to both the rising number of primary caesarean births and the rising number of repeat caesareans.

Commentary: On the clinical prediction of pre-eclampsia and its enigmatic aetiology

Background: Robson's Classification System is instrumental in benchmarking and improving maternal care. By categorizing patients based on their specific clinical circumstances, the system allows for a nuanced analysis of C-section rates and their underlying causes. Present study was aimed to assess pattern of caesarean section using Robson's ten group classification system in tertiary care hospital. Material And Methods: Present study was cross-sectional study, conducted in women who delivered via C-Section at our hospital during the study period, were then classified according to Robinson's 10 groups. Results: In our hospital, during the course of the study, out of 1000 deliveries, 391 (39.1%) were LSCS deliveries and 609 (60.9%) were vaginal deliveries. As per ROBSON ten group classification system among various groups, maximum proportion of LSCS (LSCS rate) (100%) was observed in group 9 (women with abnormal lie), followed by 75.5% in group 5 (women with previous LSCS, single cephalic, >37 weeks) and 42.5% in nulliparous patients with single cephalic, >37 weeks in group 1 (spontaneous labour).Lowest LSCS rate was observed in group 8 (women with multiple pregnancies). Maximum number of patients of LSCS were from Category 5 (women with previous CS, single cephalic, >37 weeks) (191, 48.8%) and from Category 2 (Nulliparous women, single cephalic, >37 weeks, induced or CS before labor) (117, 29.9%). Minimum patients were in Category 9 (women abnormal lies) (2, 0.5%) and Category 8 (women with multiple pregnancies) (5, 1.3%). Conclusion: The application of ROBSON'S criteria to assess the pattern of caesarean sections in the study has provided valuable insights into the distribution and trends of caesarean deliveries within the sample size. The study revealed that majority of caesarean sections were concentrated within ROBSON'S group 5 – 48.8% (All multi-parous women, at least one previous uterine scar, single, cephalic,>37 weeks gestation).

Background Preterm birth before 37 weeks of gestation is a global public health challenge, particularly in India, where the prevalence varies regionally. Understanding risk factors, such as maternal age and complications like hypertensive disorders, is vital. India's diverse healthcare landscape and regional disparities further complicate this issue. Preterm infants face increased mortality and morbidity risks like respiratory distress and intraventricular hemorrhage. This study in a tertiary care hospital aimed to analyze risk factors, assess perinatal outcomes, and contribute to the understanding of preterm birth in this complex context, providing valuable insights for maternal and child health strategies. Methods This retrospective cohort study was conducted at the Venkateshwara Institute of Medical Science, Rajabpur, over one year, extracting data from electronic health records. The study aimed to analyze risk factors associated with preterm delivery and assess perinatal outcomes. The study included diverse pregnancies, both singleton and multiple gestations, and employed sample size calculations to ensure statistical validity. Trained medical personnel collected extensive data on maternal characteristics, obstetric history, antenatal care, perinatal outcomes, and mode of delivery. Statistical analysis, utilizing SPSS (IBM, Chicago, USA), involved descriptive statistics, comparative analysis, chi-square tests, t-tests, Mann-Whitney U tests, and multivariate logistic regression models. Findings with a p-value <0.05 were considered significant. Results The study included 2042 deliveries, with a preterm birth prevalence of 14.2%. Multiparous women had higher preterm birth rates than primigravida (72.92% vs. 27.08%). Maternal age, history of preterm delivery, hypertensive disorders, inadequate antenatal care compliance, previous cesarean section, multiple gestations, antepartum hemorrhage (APH), polyhydramnios, oligohydramnios, and premature rupture of membranes (PROM) were significantly associated with preterm birth. Apgar scores at one minute and five minutes, neonatal complications, and mortality rates were notably worse among preterm births. Vaginal delivery rates were significantly lower in the preterm group (36.3%) compared to full-term deliveries (48.8%), with a higher rate of emergency cesarean sections (19.7% vs. 10.8%). Conclusion This study provides valuable insights into the risk factors and perinatal outcomes of preterm delivery at a tertiary care hospital, with precise values illustrating the extent of associations. The findings such as history of preterm delivery, hypertensive disorders, and inadequate antenatal care compliance as the most commonly associated conditions with preterm birthand management of such associated conditions may help reduce the rate of premature birth.

OBJETIVOS: Describir las características epidemiológicas y resultados obstétricos y perinatales en gestantes después de los 40 años. DISEÑO: Estudio Descriptivo retrospectivo.MATERIAL Y MÉTODOS: Se revisó las historias clínicas de todos los partos ocurridos en mujeres de 40 años o más atendidos en el IEMP del 1 enero del 2004 al 30 de noviembre de 2004. RESULTADOS: Se atendió 18568 partos, de los cuales 516 correspondieron a mujeres de 40 años o más, con una incidencia de 2.78%. Se distinguió 2 grupos, el grupo de nulíparas (n=46) y el grupo de multíparas (n=470). El 58.2% tenía entre 40 y 42 años al momento del parto. Ambos grupos tenían similares características en cuanto a edad promedio, estado civil, IMC y número de controles prenatales. La tasa de cesáreas en toda la población fue alta (56,8%) y mayor en el grupo de nulíparas (71,7%; p&lt;0,01). El grupo de nulíparas presentó mayores casos de partos disfuncionales, en los que se usó oxitocina (52,2%; p&lt;0,05). Se registró 15 (0,8%) muertes fetales intrauterinas, todas en mujeres multíparas. Hubo mayor tasa de partos pretérmino que en la población general, el grupo de nulíparas tuvo una tasa de 21,7%, sin diferencia significativa. Las mujeres multíparas tuvieron mayor número de neonatos macrosómicos (11,3%), que el grupo de nulíparas (p&lt; 0,05). CONCLUSIONES: Las nulíparas mayores de 40 años tienen mayor riesgo de parto disfuncional y mayores tasas de cesárea y pretérminos y las multíparas, mayor riesgo de muerte fetal intrauterina y macrosomia fetal.

Effect of body mass index on intrauterine insemination cycle success