The empty sella

The empty sella

The Empty Sella Renato Spaziante, M.D.,* Enrico de Divitiis, M.D.,t Lucio Stella, M.D.,* Paolo Cappabianca, M.D.,* Luigi Genovese, M.D.* The data fro...

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The Empty Sella Renato Spaziante, M.D.,* Enrico de Divitiis, M.D.,t Lucio Stella, M.D.,* Paolo Cappabianca, M.D.,* Luigi Genovese, M.D.*

The data from 55 patients with empty sellae seen during the past five years are examined. The clinical and radiological features most helpful in defining and classifying each case are identified. The most frequent and most serious complications and the warning signs useful in diagnosis are discussed. The indications for and the results of surgical treatment are reviewed.

Materials and Methods We studied 55 cases of empty sella, independent of their individual nature. Radiological studies included plain roentgenograms of the skull and stratigraphy (preferably hypocycloidal) of the sella turcica (all cases), CT scan (all of the last 35 cases), pneumoencephalography (all cases), perihypophyseal phlebography [11, 13] (6 cases, 11%), and Spaziante R, de Divitiis E, Stella L, Cappabianca P, radioisotope cisternography (3 cases, 5.5%). Genovese L: The empty sella. Surg Neurol Studies of the visual fields were always performed by one 16:418-426, 1981 team, each time using the same technique. Pituitary function was studied using basal serum levels Although the empty sella has been known for over thirty for growth hormone (GH), prolactin (PRL), follicleyears [7], and although from the beginning there have been stimulating hormone (FSH), luteinizing hormone (LH), numerous studies defining many of its anatomic [4, 7], thyroid-stimulating hormone (TSH), adrenocorticotroradiological [3, 17, 33, 39], and endocrinologic [26, 33] pic hormone (ACTH), testosterone, estradiol, Ta, T4, features, there is still much confusion since the classifica- and cortisol and by stimulation and inhibition tests tion is not clear, nosographic perspectives are uncertain, (thyrotropin-releasing hormone [TRH], luteinizing horand nomenclature is often incorrect. The absence of a mone releasing hormone [LHRH], bromoergocryptine, synthetic overview of the features of this entity is det- L-dopa, arginine, insulin-induced hypoglycemia, and glurimental to the correct diagnosis of individual cases. Empty cose tolerance) of the chief pituitary hormones. sella is not a disease but an anatomic state with characteristic radiological findings: it may be caused by many different Radiolo~cal Studies pathological conditions, both pituitary and nonpituitary, PLAIN ROENTGENOGRAMS OF THE SKULL AND STRATIGRAPHY which must be diagnosed and interpreted correctly on each OF THE SELLaTURClCA. In 5 cases (9%) the sellae were of normal volume and rounded in shape. In all the others, occasion. We describe here the cases of 55 patients seen during the sellar diameters and volumes were increased and there were past five years in whom detailed radiological, endocrin- characteristic changes of profile: rounded (20 cases, 36%), ologic, and ophthalmological investigations were carried quadrangular (13 cases, 23%), deep (9 cases, 17%), cuplike out. We have excluded cases seen more than five years ago (6 cases, 11%), and omega shaped (2 cases, 4%). In 21 and those in which, for whatever reason, the studies were cases (38%) the sellar floor was markedly asymmetrical. not sufficiently complete to ensure a correct diagnostic in- Structural changes and erosion of bone cortex were seen in terpretation. Our aim is to identify those features that allow 8 cases (15%) (Fig. 1). one, when faced with the radiological finding of an empty sella, to make a precise and confident diagnosis, to make a COMPUTEDTOMOGRAPHY(CT SCAN). This was carried out in correct judgment as to prognosis, and to suspect and dis- all of the last 35 patients. In all of these 35 patients, typical hypodensity was seen in both axial and coronal views and cover other, more serious associated diseases. there were the same changes in shape and profile of the sellae as observed on plain roentgenograms. In 3 cases of benign intrasellar cyst and in 1 case of cystic From the *Clinica Neurochirurgica e tCattedra di Neurochirurgia Fun- adenoma, however, the CT findings were indistinguishable zionale, Second Faculty of Medicine and Surgery, University of Naples, from those of an empty sella. Due to a partial volume effect Italy. [24, 38], marked intrasellar hypodensity was also seen in Address reprint requests to Dr. Renato Spaziante, Clinica Neurochirurgica, many normal patients with a hyperpneumatized sphenoid 2nd Facolt~ di Medicina e Chirurgia, Via Pansini 5, 80131 Napoli, Italy. sinus or with dilated perisellar cerebrospinal fluid spaces. Key words: empty sella; pituitary tumors; pneumoencephalography; comThis type of picture can lead to an erroneous and unjustified puted tomography; trigeminal neuralgia. 418

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D Fig. I. Radiograms (above) and synoptic diagrams (below) of the characteristic sellar changes observed in our patients, with their respective percentages of frequency. The dimensions used to appraise the sellar shapes and volumes are shown: a = sellar entrance; b = sellar length; c = sellar depth. (A) Rounded seUa turcica of normal volume (5 cases), (B) balloon-shaped sella (20 cases), ( C) quadrangularshaped sella ( 13 cases), ( D) deep sella (9 cases), (E) cuplike sella (6 cases), ( F) omega-shaped sella (2 cases).

manual tapping of the cranium to facilitate the bubbling of gas through the diaphragm into the sella turcica [16] and hanging-head [3, 29] techniques). In the other cases the cisternal hernia was anterior in 17 (31%), horizontal in 16 (29%), and extensive in 18 (33%). The axis of the third ventricle was distorted and displaced laterally toward the asymmetrical sellar floor in 12 cases (12%). The chiasmal point was frequently displaced toward the center of the arachnoidocele, as described by Bajraktari and associates

suspicion of empty sella (Fig. 2). In 3 cases of associated pituitary microadenoma, the presence of which was suspected on the basis of data from hormone studies, computed tomography failed to demonstrate adenomatous tissue even after enhancement with contrast media.

[3], RADIOISOTOPE CISTERNOGRAPHY.This confirmed the presence of an empty Sella in 3 of the 4 cases not diagnosed by pneumoencephalography.

PNEUMOENCEPHALOGRAPHY.This was performed in all cases (Fig. 3). In 4 (7%) there was no air-filling of the arachnoid diverticulum despite the use of special procedures (gentle

PERIHYPOPHYSEALPHLEBOGRAPHY.This was carried out in 6 patients (Fig. 4). In 3 a suspected associated pituitary adenoma was confirmed by signs of asymmetrical compres-

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Fig. 2. Schematic explanation 4possible false positives on CT scan. Widened cisternal spaces (A) or hyperpneumatized sphenoidal sinus (B) can give a CT image 4marked intrasellar hypodensity due t~) a partial volume e~ect. This can lead to a mistaken suspicion of empty sella in spite of a technically correctly perfin'med examination.

sion or amputation of cavernous or intercavernous structures. In the other 3 there was symmetrical widening of the distances between perihypophyseal venous structures, with neither asymmetry nor signs of localized compression. These findings allow one to exclude an expanding lesion (adenoma) within the pituitary fossa. CEREBRALANGIOGRAPHY.This was performed sporadically, not to investigate the empty sella (in the diagnosis of which it is of little value [12]), but to explore other associated lesions. The main angiographic feature of the empty sella was a bilateral and symmetrical lateral shift of the intracavemous part of the carotid siphons. Occasionally the descent of the initial portion of the anterior cerebral artery into the sellar cavity was observed [12]. Ophthalmological Studies

The visual fields were found to be normal in 40 cases (73%) (Fig. 5). Pathological changes were found in the remaining 15 cases (27%): concentric peripheral narrowing (7 cases, 13%), concentric peripheral narrowing plus widening of the blind macular region (1 case, 2%), deficit of the bitemporal hemianopia type (6 cases, 10%), and complete blindness in 1 case of acute postoperative empty sella. Two thirds of these field defects were found in patients with secondary empty sellae. Papilledema or atrophic changes, or both, of the optic disc were found in 20% of the cases (3 primary, 8 secondary empty sellae). Endocrinologic Studies

In 27 cases (49%) both basal and dynamic endocrinologic studies demonstrated normal pituitary functioning (Fig. 6). In 8 cases (15%) there was a modest monotropinic deficit shown by dynamic tests alone; in 2 cases (3%) there was a

mild functional hyperprolactinemia that was not related to the overproduction of a secreting adenoma [25]. This group, which can be defined as "normal," thus consisted of 37 cases (67%) of which 29 (78%) were cases of primary empty sella. In 4 of these cases we have discovered an occasional marked hypersecretion of A C T H (800 to 1,000 pg/ml) without any symptoms of Cushing's syndrome; there have been normal levels of cortisol and maintained diurnal cortisol rhythm in 3 cases and hypocortisolism in the fourth. We are investigating these cases with regard to the biological activity of these hormones, but up to now we have not been able to provide a reasonable hypothesis for this peculiar phenomenon. Marked changes of pituitary function were seen in 18 cases (33%). In 10 (18%) there was marked pluritropinic hypopituitarism; only 3 of these cases were primary types. In 8 cases (15%) marked hypersecretion of a pituitary hormone with highly abnormal values led to the suspicion of an associated secreting pituitary adenoma. This was confirmed at operation (5 growth hormone-secreting, 1 prolactin-secreting, and 2 adrenocorticotropic-secreting adenomas).

Classification Based on clinical history, radiological, ophthalmological, and endocrinologic findings, and the later evolution of symptoms, the cases were divided into two groups: primary or idiopathic empty sella, and secondary or symptomatic empty sella (Table). There were 32 cases in the first group (58% of the total), of which 24 (75%) were female and 8 (25%) were males, with ages ranging from 19 to 63 years. There were only 5 cases (16%) that conformed to the typical stereotype, as described in the literature [29], of multiparous, middle-aged women who are characteristically obese and with headaches as their only complaint. There was, however, a female preponderance, the incidence was chiefly in middle age (19 patients, 60%, were between 36 and 45 years old), and clinically the syndrome was benign: there was no neurological deficit in any of these patients; visual field defects were rare (findings in 27 patients, 85%, were completely normal); and endocrine changes were minimal (in 29 patients, 91%, hormone profiles were normal or deviated only slightly from normal, as already mentioned). All cases were classed in the first group in which there was neither evidence based on the clinical or radiological findings or in the patient's history nor suspicion of past or present disease referable to the empty sella. In most of these patients investigations leading to the final diagnosis had begun with the chance finding of morphological alterations of the sella turcica. The second group, on the other hand, consisted of those cases in which some pathological cause for the empty sella

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Fig, 3. Characteristic pneumoencephalographic features observed in our patients (above) with schematic drawings and respective percentages of frequency (below). ( A) A small subdiaphragmatic cistern is frequently observed when chiasmatic cisterns are properly filled and the necessary maneuvers are performed. This finding does not justify a diagnosis of empty sella. (B) Typical horizontal herniation ( 16 cases). ( C) Typical anterior herniation (17 cases). ( D) Typical extensive herniation ( 18 cases). ( E) Displacement of the chiasmal point (a) is a useful landmark of empty sella; with respect to its natural situation, it is generally lowered and displaced toward the center of the arachnoid diverticulum (asterisk). o -- center of sella turcica. (F) In the anteroposterior projection an asymmetrical displacement of the axis of the third ventricle toward the deepest side of an asymmetrical sellar floor is frequently observed. We found it in 12 of 13 (90%) of our cases of primary empty sella with asymmetry of the sellar floor.

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$7¢ASlS(29/b) Fig. 4. Perihypophyseal phlebogram. ( A) Clear signs of markedly asymmetrical compression of the anterior intercavernous sinus (arrows) lead to the suspicion of a coexisting partially necrosed pituitary adenoma (confirmed at operation) (white mark is an artifact). ( B) Regular widening of the sellar diameters without signs of localized compression leads to the diagnosis o:f primary empty sella without associated lesions, as confirmed at operation.

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could be demonstrated or the suspicion of its presence was highly likely to prove correct. There were 23 cases (42% of the total) in this group, of which 13 (57%) were female and 10 (43%) were male, aged between 13 and 75 years. We divided the various etiological types into two main categories according to their clinical course, since this determines the choice of treatment and the need for periodic follow-up. In the nonprogressive types, the empty sella is merely accessory to other complex lesions that have already resolved or with courses entirely independent of the empty sella. This group includes cases of empty sella secondary to

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Fig. 6. Synopsis of the endocrinologlc features observed in our patients. Above: summary of the cases with normal or slightly deviated function (mild, functional hyperprolactinemia; normal function; mMerate monotropinic deficit) generally associated with a primary empty sella (depicted in circle A). Below: summary of the cases with clearly altered pituitary function (high hypersecretion, marked hypopituitarism) generally associated with a secondary empty sella (depicted in circle B as secondary empty sella due to a partially necrosed pituitary adenoma). PRL = prolactin; ACTH = adrenocorticotropic hormone; TSH = thyroid-stimulating hormone; FSH-LH = follicle-stimulating hormone-luteinizing hormone; GH = growth hormone; PAN-IPO = pluritropinic hypopituitarism (3 cases primary empty sella, 7 cases secondary empty seUa). Superscript numbers in lower figure refer to number of observed cases of pituitary adgnomas.

Summary of Cases Reported Patient Data

Primary Empty Sella

F 24 (75%) M 8 (25%) Age (yr) 19 to 63 Neu . . . . Oph. 5 (15%) End. 3 (9%)

Secondary Empty Sella

Overall Total

13 10 13 3 10 15

37 (67%) 18 (33%) 13 to 75 3 (5%) 15 (27%) 18 (33%)

(57%) (43%) to 75 (13%) (43%) (65%)

F = female; M = male; Neu. = incidence of neurologicaldeficits; Oph. = ophthalmological symptoms; End. = major endocrine disturbances.

spontaneous hypophyseal atrophy or necrosis (3 cases, 13%); increased intracranial pressure, especially benign intracranial hypertension (2 cases, 9%); intracranial tumors (undiagnosed when investigations were commenced) without raised intracranial pressure (2 cases, 9%); and certain cases secondary to primary hypothyroidism (which we be-

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lieve it worthwhile to mention here, although they are not described in this paper since they are still undergoing full investigation). In the progressive types, the underlying lesion is the sellar pathology and the empty sella. There is a progressive course both anatomically and with respect to symptoms; thus careful follow-up is essential. In practice, these are cases of empty sella secondary to radiotherapy to the pituitary (3 cases, 13%), pituitary surgery (3 cases, 13%), and spontaneous partial or total liquefaction of a pituitary adenoma (10 cases, 44%). The first two of these were previously defined [8, 30] as the "empty sella syndrome." Since this term was later incorrectly applied to other types of empty sella, even completely asymptomatic ones, causing great confusion, we consider it desirable to draw attention to the limits within which the term should be used.

Complications Progression of the anatomic condition (cisternal herniation) is fortunately rare. It is independent of the etiology but occurs more frequently in secondary types (Fig. 7). We have seen 2 cases (4%) of cerebrospinal fluid rhinorrhea (1 with a primary empty sella, the other associated with a pituitary adenoma); 10 cases (18%) of partial or total prolapse of the optic nerves into the sellar cavity (3 in primary, 7 in secondary empty sella) associated with atrophic changes of the optic discs; 5 cases (9%) of trigeminal neuralgia (2 in primary, 3 in secondary empty sella, in 2 of which there was an associated oculomotor nerve defect); 3 cases (5%) of progressive impairment of pituitary function (3 cases of primary empty sella). Surgical treatment was carried out in a patient with an acute postoperative empty sella, in whom already seriously impaired vision suddenly deteriorated to blindness due to prolapse of the optic nerves into the sella following the emptying of a voluminous intrasellar and suprasellar arachnoid cyst [42]. Reduction of the arachnoidocele and chiasmapexy were unsuccessful. In a case of cerebrospinal fluid rhinorrhea, surgical repair was successfully performed to the sellar floor, using lyophilized dura mater, and extradural plugging with muscle. Two patients with trigeminal neuralgia recovered after surgical treatment. Operations were also successful in 8 patients with empty sella secondary to partial necrosis of a pituitary adenoma; in each patient there was liquefied adenomatous tissue over which a cisternal hernia projected.

Discussion Extension of the chiasmatic cisterns beneath the line of the diaphragm is a fairly common finding and is more frequent than had been thought in the past [6]. This condition is universally defined as empty sella, irrespective of the etiology or clinical manifestations. It is therefore essential to define precisely the various conditions that can produce an

Fig. 7. Synopsis of the most important complications observed. ( A) Cerebrospinal fluid rhinorrhea (2 cases) due to erosion of the sellar floor and tearing of the dura mater and arachnoid. (B) Prolapse of the optic pathways in the sellar cavity due to the pulsatile action of cere. brospinal fluid and third ventricle and the downward attraction exerted by possible arachnoidal adhesive scars ( 10 cases). ( C ) Progressive panhypopituitarism caused by the pulsatile compression of cerebrospinal fluid on the pituitary gland (3 cases). ( D) Trigeminal neural~a (5 cases) with ophthalmoplegia (2 cases) caused by distension and compression of the perisellar dural structures. empty sella. This is all the more true today, when systematic radiological investigations of the sella for many endocrine diseases and regular use of CT scan, even in minor disorders, give rise much more frequently to the chance finding (or, more appropriately, the fortuitously early finding) of changes in sellar volume or of intrasellar hypodensities, which are subsequently shown to be related to cisternal herniation [38]. We believe it is important to stress certain points that came out of our data. For diagnosis, the neuroradiological protocol must be complete. In most cases pneumoencephalograms and CT scans are in agreement, and certain diagnosis rests on their combined results. The possibility of false negative pneumoencephalograms [19] and false positive CT scans [2, 24, 40] must be carefully considered in cases in which the two findings are not in agreement; under these circumstances cisternography is essential, using radioisotope [5, 9, 41] or, better still, anionic iodinated contrast medium [20, 24, 45]. Use of anionic iodinated contrast medium also enables one to perform tomodensitometry [2, 20], which is indispensable in cases of cerebrospinal fluid rhinorrhea [ 14, 19, 37, 40]. In patients in whom an associated adenoma is suspected, perihypophyseal phlebography [11] provides a most useful aid to diagnosis. Although neuroradiological investigation ascertains most of the pathological features of the lesion, clinical findings

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(visual fields, hormone levels, past history, the course of the symptoms) often provide the data for the correct classification of each case. This observation is of extreme importance when one considers the different implications inherent in the diagnosis of primary or secondary empty sella. Primary empty sella is an almost entirely benign condition, rarely causing complications and giving rise to only minimal signs and symptoms [29]. Secondary empty sella is usually also benign, but often there are more signs and symptoms, the frequency of more serious complications is greater, and there is a marked tendency toward both anatomic and clinical progression. To put each case into perspective using correct criteria for classification is of fundamental importance. Opinions as to prognosis and treatment are dependent on this, since the etiology and pathogenesis are completely different for the two types [ 12], i.e., accentuation of physiological and paraphysiological phenomena in primary cases and frankly pathological lesions, even if often benign, in secondary cases. Provided every effort has been made to exclude any associated pathology, the diagnosis of primary empty sella is most reassuring and the prognosis is good. In our opinion, suspicious findings include all ophthalmological signs (changes in the fundus or the visual fields); marked deviations from normal of pituitary hormone levels (signs of hyperactivity always--with the previously mentioned exception of functional hyperprolactinemia--indicate an associated adenoma); marked unevenness of the sellar floor, without corresponding lateral displacement of the third ventricle (in this case it is thought that its asymmetrical pulsation is responsible for the development of asymmetrical bone changes [3]; otherwise one would suspect an associated expanding lesion); and features from the history (for example, acute episodes of raised intrasellar pressure or of alterations of hormone function, episodes of inflammation or of benign intracranial hypertension) leading one to sus-

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pect other pituitary or extrapituitary pathology. When all the findings are in agreement and indicate a primary empty sella, we believe that this diagnosis can be made with a reasonable margin of safety. Extremely useful in this respect are a deep or quadrangular sella (fairly typical of this condition but rather rare in pituitary adenoma [ 1]), lack of asymmetry or of structural changes with a marked increase of sellar size, and conservation of pituitary function despite greatly reduced volume [18]. In the absence of these findings, clinical and radiological investigations must be performed fully and with utmost care, and must be repeated if necessary, so that any associated pathology will be revealed. Continued observation is essential in all cases. The frequency of these examinations varies in each patient according to the risk factors involved, the etiology, and the clinical course. Variations in the visual fields, marked changes in hormone levels, alterations of sellar profile, rhinorrhea, and onset of severe, persistent headache or of trigeminal neuralgia [28] due to distension of the dura mater of the sellar floor or due to compression of the wall of the cavernous sinus, are all warning signs. Their occurrence should lead one both to revise the entire clinical case and to consider the possibility that complications arising during the natural course of an empty sella (such as herniation of the optic structures [8, 27], erosion of the sellar wall [2], or rupture of the arachnoid [10, 15, 19, 43] with consequent cerebrospinal fluid rhinorrhea caused by the pulsatile action of the cerebrospinal fluid, involution and atrophy of the pituitary due to both compression by and the pulsatile acFig. 8. Schematic drawing and intraoperative radiogram of an extradural plugging of the hypophyseal fossa during an operation for empty sella. Continuous intraoperative spinal drainage is very useful in lifting the dura mater from the sellar floor and in reducing the arachnoidocele.

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Surgical results, however, are influenced more by appropriate action and timely intervention for given indications rather than by the method used. In cases in which indications exist, it is important to operate early so that the worst complications can be forestalled. With respect to the postoperative type of empty sella, we underline the gravity and unexpected suddenness of the visual disturbances; these often respond poorly to treatment, rendering an operation useless [22, 31]. Their prevention is best achieved by accurate tamponade of the sellar cavity when predisposing factors exist [21, 34]. In the same way, better selection of cases for external or interstitial radiotherapy will reduce the incidence of empty sella secondary to radiotherapy, which usually exhibits very severe clinical signs initially.

Fig. 9. Intraoperative radiogram of air encephalography during the sellar plugging of an empty sella secondary to the partial necrosis of a growth hormone-secreting adenoma, unsuccessfully irradiated five years before.

Presented at the XX1X Congress of the Italian Society of Neurosurgery, Rome, November 20-22, 1980.

References 1. Bajraktari X: Skull changes with intrasellar cisternal herniation (empty sella). Neuroradiology13:89-96, 1977 tion of the arachnoidocele [27], or increased pressure on 2. Bajraktari X, Bergstr/3mM, Brismar K, Goulatia R, Greitz T, Grepe perihypophyseal dural structures [32, 35]) have occurred. A: Diagnosis of intrasellar cisternal herniation by computer assisted Under these circumstances, the indications for surgical tomography. J Comput Assist Tomogr 1:105-116, 1977 treatment must be evaluated with care: pre-existing com3. Bajraktari X, Grepe A, Goulatia RK: Pneumoencephalographic changes with intrasellar cisternal herniation (primary empty sella). plications for which an operation cannot be delayed, such Neuroradiology 13:97-105, 1977 as visual and pituitary deficits, tend not to regress much 4. Bergland RM, Ray BS, Torack RM: Anatomical variations in the following operation [21, 31]. The chief aim is to arrest their pituitary gland and adjacent structures in 225 human autopsycases. J Neutosurg 28:93-99, 1968 progressive course. Cerebrospinal fluid rhinorrhea is often 5. Brisman R, Hughes JEO, Mount LA: Cerebrospinal fluid rhinorrhea complicated by serious infection, and it has a marked tenand the empty sella. J Neurosurg 31:538-543, 1969 dency to recur [10, 19]. 6. Brismar K, Bajraktari X, Goulatia R, Efendtc S: The empty sella syndrome--intrasellar cisternal herniation--in "normal" patients The surgical procedure must attempt to restore normal and in patients with communicating hydrocephalus and intracranial anatomic conditions by reducing the arachnoidocele and by tumors. Neuroradiology 17:35-43, 1978 7. BuschW: Die Morphologieder Sella turcica und ihre Beziehungenzur chiasmapexy, and to repair interruptions of the dura mater Hypophyse. Virchows Arch [Pathol Anat] 320:437-458, 1951 and of the sellar floor without causing further damage to 8. Colby MY Jr, Kearns TP: Radiation therapy of pituitary adenomas local delicate structures, possibly preventing the more imwith associated visual impairment. Proc Staff Meet Mayo Clin 37:15-24, 1962 portant complications [27, 44]. We believe that the trans9. Dany A, Tapie P, PefferkornJP, Bebear JP, Pradet JM, Claude M, sphenoidal route is the most suitable for this, and that after Vallat JN: Selle turcique vide ou selle turcique ouverte?Apropos de 3 widespread detachment of the dura mater from the sellar observations personelles. Neurochirurgie 19:225-231, 1973 floor, it is best to restrict oneself to accurate extradural 10. Davis S, Kaye AH: A dynamic pressure study of spontaneous CSF rhinorrhea in the empty sella syndrome. J Neurosurg 52:103-105, plugging [21, 36] (Fig. 8) unless there are other indications 1980 for exploring the pituitary fossa. Air encephalography dur- 11. De Divitiis E, Spaziante R, Iaccarino V, Stella L, Genovese L: ing operation provides useful fluoroscopic monitoring of variPhtebography of the cavernous and intercavernous sinuses. Surg Neurol 15:306-312, 1981 ous stages of the operation [23] (Fig. 9). Continuous spinal 12. De Divitiis E, Spaziante R, Stella L: Empty sella and benign intradrainage both during the operation and for 48 hours aftersellar cysts, in Krayenbiihl H (ed): Advances and Technical wards assists in lowering tension in the arachnoidocele, in Standards in Neurosurgery. Vienna, New York: Springer-Verlag, 1981, Vol 8, pp 1-75 detaching and lifting the dura mater, in reducing the cis13. Delvert JC, Th~ron J, Laffont J, Santini JJ, Gouaz~ A: Bases ternal herniation, and in preventing a possible cerebrospianatomiques de l'exploration radiologique des sinus intercaverneux/~ nal fluid fistula [21, 27]. The dura mater need be opened la recherche des expansions intrasellaires. Anat Clin 1:301-307, 1979 only when an associated pituitary adenoma is suspected or if 14. Dohrmann GJ, Patronas NJ, Duda EE, Mullan S: Cerebrospinal fluid there is cerebrospinal fluid rhinorrhea. If there is cerebrorhinorrhea: localization of dural fistulae using metrizamide, hypocyspinal fluid rhinorrhea, it is necessary to repair the dura cloidal tomographyand computed tomography. Surg Neurol 11:373377, 1979 mater with lyophilized dura mater and to perform a mixed 15. Drolet M, Bouche B, B~langerC: Syndromede la grosseselle turcique intradural and extradural plugging, possibly with fixation vide et de la rhinorrh~e du liquide c6phalorachidien. Can Med Assoc [28, 43]. J 107:1199-1201, 1972

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