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Lundholm MD, Yogi-Morren D. A Comprehensive Review of Empty Sella and Empty Sella Syndrome. Endocr Pract 2024; 30:497-502. [PMID: 38484938 DOI: 10.1016/j.eprac.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Abstract
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.
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Affiliation(s)
- Michelle D Lundholm
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, Ohio
| | - Divya Yogi-Morren
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, Ohio.
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2
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Bartmann IR, Kallenberg K, Alnawaiseh M, Mihailovic N. [Empty sella syndrome and/or normal tension glaucoma?]. DIE OPHTHALMOLOGIE 2023; 120:318-322. [PMID: 35482082 DOI: 10.1007/s00347-022-01637-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 03/28/2022] [Accepted: 04/02/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Iva R Bartmann
- Klinik für Augenheilkunde, Klinikum Fulda gAG, Universität Marburg Campus Fulda, Fulda, Deutschland.
| | - Kai Kallenberg
- Klinik für Radiologie, Klinikum Fulda gAG, Universität Marburg Campus Fulda, Fulda, Deutschland
| | - Maged Alnawaiseh
- Klinik für Augenheilkunde, Klinikum Fulda gAG, Universität Marburg Campus Fulda, Fulda, Deutschland
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Münster, Deutschland
| | - Natasa Mihailovic
- Klinik für Augenheilkunde, Klinikum Fulda gAG, Universität Marburg Campus Fulda, Fulda, Deutschland
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Münster, Deutschland
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How I do it: endoscopic endonasal chiasmopexy for optic chiasm prolapse. Acta Neurochir (Wien) 2022; 164:2115-2118. [PMID: 35781540 DOI: 10.1007/s00701-022-05300-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Prolapse of the optic system into an empty sella is an unusual complication of the management of pituitary tumors. METHOD We described the technical nuances for an endoscopic endonasal chiasmopexy, the indications for the procedure, and the caveats on the diagnosis of optic chiasm prolapse. CONCLUSION The endoscopic endonasal chiasmopexy provides a direct route to lift the optic system. In most cases, the procedure may be achieved extradurally, protecting the chiasm from manipulation and postoperative fibrosis.
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Winograd E, Kortz MW, Lillehei KO. Radiographic pituitary stalk disruption: A rare sequela of secondary empty sella syndrome. Surg Neurol Int 2021; 12:385. [PMID: 34513152 PMCID: PMC8422539 DOI: 10.25259/sni_530_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022] Open
Abstract
Background: This two-patient case series describes a rare sequela of postoperative empty sella syndrome (ESS) following transsphenoidal resection of pituitary macroadenomas. This is characterized by progressive hormone dysfunction, diabetes insipidus (DI), and associated MRI evidence of pituitary stalk disruption. Case Description: This phenomenon was retrospectively evaluated in a review of 2000 pituitary tumor resections performed by a single neurosurgeon (KOL). Chart review was retrospectively conducted to gather data on demographics, pituitary hormone status, tumor characteristics, and management. We identified 2 (0.1%) cases of progressive pituitary endocrine dysfunction occurring in the postoperative period associated with MRI evidence of pituitary stalk disruption within 6 weeks of discharge from the hospital. This was felt to be caused by the rapid descent of the residual normal pituitary gland down to the floor of the postoperative empty sella, causing relatively swift stalk stretching. Both patients developed DI, and one patient demonstrated increased pituitary hormone dysfunction. Conclusion: This phenomenon is a rare manifestation of postoperative ESS, secondary to surgical resection of a pituitary macroadenoma. We discuss the associated potential risk factors and strategies for avoidance in these two cases. Routine instillation of intrasellar fat in patients at risk is felt to be protective.
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Affiliation(s)
- Evan Winograd
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Michael W Kortz
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kevin O Lillehei
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado, United States
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Graillon T, Passeri T, Boucekine M, Meyer M, Abritti R, Bernat AL, Labidi M, Dufour H, Froelich S. Chiasmapexy for secondary empty sella syndrome: diagnostic and therapeutic considerations. Pituitary 2021; 24:292-301. [PMID: 33136230 DOI: 10.1007/s11102-020-01104-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Secondary empty sella syndrome (SESS) following pituitary surgery remains a diagnostic and therapeutic challenge. The aim of this study was to specify the diagnostic criteria, surgical indications and results of chiasmapexy in the SESS. METHODS Three cases from two experienced neurosurgical centers were collected and the available literature was reviewed. RESULTS The 3 patients were operated for a giant non-functioning pituitary adenoma, a cystic macroprolactinoma, and an arachnoid cyst respectively. Postoperative visual outcome was initially improved, and then worsened progressively. At the time of SESS diagnosis, visual field defect was severe in all cases with optic nerve (ON) atrophy in 2 cases. Patients were operated via an endoscopic endonasal extradural approach. One patient was re-operated because of early fat reabsorption. Visual outcome improved in 1 case and stabilized in 2 cases. Statistical analyses performed on 24 cases from the literature review highlighted that patient age and severity of the preoperative visual defect were respectively significant and nearly significant prognostic factors for visual outcome, unlike the surgical technique. CONCLUSION T2-weighted or CISS/FIESTA sequence MRI is mandatory to visualize adhesions, ON kinking and neurovascular conflict. TS approach is the most commonly used approach. The literature review could not conclude on the need for an intra or extradural approach suggesting case by case adapted strategy. Intrasellar packing with non-absorbable material such as bone should be considered. Severity of the visual loss clearly decreases the visual outcome suggesting early chiasmapexy. In case of severe and long standing symptoms before surgery, benefits and surgical risks should be carefully balanced.
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Affiliation(s)
- Thomas Graillon
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, Marseille, France.
| | - Thibault Passeri
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Mohamed Boucekine
- EA 3279 CEReSS - Health Service Research and Quality of Life Center, Aix-Marseille Univ, School of Medicine - La Timone Medical Campus, |27 bd Jean Moulin Cedex 05, 13385, Marseille, France
| | - Mikael Meyer
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, Marseille, France
| | - Rosaria Abritti
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Anne-Laure Bernat
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Moujahed Labidi
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
| | - Henry Dufour
- Neurosurgery Department, Aix-Marseille Univ, APHM, CHU Timone, Marseille, France
| | - Sébastien Froelich
- Neurosurgery Department, Hôpital Lariboisiere, APHP, Université Paris Diderot, Paris, France
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Tabak M, Pelsma ICM, Kruit MC, van Furth WR, Biermasz NR, Notting IC. Chiasmal herniation following treatment of pituitary macroadenoma. Pituitary 2021; 24:68-78. [PMID: 33057947 PMCID: PMC7864822 DOI: 10.1007/s11102-020-01088-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2020] [Indexed: 11/06/2022]
Abstract
PURPOSE To evaluate whether the occurrence of chiasmal herniation coincides with visual field (VF) deterioration and to compare the course of VF defects in patients with and without radiological chiasmal herniation following treatment of pituitary adenoma. METHODS This retrospective cohort study included 48 pituitary macroadenoma patients with chiasm compression, divided into three groups: Group 1 (N = 12), downward displaced optic chiasm and deteriorated VFs; Group 2 (N = 16), downward displaced optic chiasm; Group 3 (N = 20), control-group matched for tumour size and follow-up VFs, in mean deviation (dB). VFs were compared over time and a severity index, Chiasm Herniation Scale (CHS), for herniation based on radiological parameters was designed. RESULTS After treatment, all groups showed improvement of VFs (Gr1: 2.97 dB p = 0.097, Gr2: 4.52 dB p = 0.001 and Gr3: 5.16 dB p = 0.000), followed by long-term gradual deterioration. The course of VFs between patients with and without herniation was not significantly different (p = 0.143), neither was there a difference in the course before and after herniation (p = 0.297). The median time till onset of herniation was 40 months (IQR 6 month-10 years) and did not significantly differ (p = 0.172) between the groups. There was no relation between VFs and the degree of herniation (p = 0.729). CONCLUSION Herniation does not appear to have clinical relevance with respect to VF outcome. The newly designed CHS is the first scoring system to quantify the severity of herniation and, in the absence of alternatives, may be useful to describe MRI findings to serve future added value in larger sized outcome studies.
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Affiliation(s)
- Marjolein Tabak
- grid.10419.3d0000000089452978Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
- grid.10419.3d0000000089452978Center for Pituitary Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris C. M. Pelsma
- grid.10419.3d0000000089452978Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- grid.10419.3d0000000089452978Center for Pituitary Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark C. Kruit
- grid.10419.3d0000000089452978Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- grid.10419.3d0000000089452978Center for Pituitary Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R. van Furth
- grid.10419.3d0000000089452978Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- grid.10419.3d0000000089452978Center for Pituitary Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R. Biermasz
- grid.10419.3d0000000089452978Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- grid.10419.3d0000000089452978Center for Pituitary Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Irene C. Notting
- grid.10419.3d0000000089452978Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
- grid.10419.3d0000000089452978Center for Pituitary Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
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Ezeh E, Akotanchi BN, Ezeh R. Primary empty sella syndrome presenting with profound bilateral visual loss. NIGERIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4103/njm.njm_2_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Vetrano IG, Broggi M, Acerbi F. Commentary: Symptomatic Primary Tethered Optic Chiasm: Technical Case Report. Oper Neurosurg (Hagerstown) 2020; 19:E446-E447. [PMID: 32442271 DOI: 10.1093/ons/opaa146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ignazio G Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Yamada S, Yagi K, Hirano K, Uno M. Spontaneous improvement of secondary empty sella syndrome due to re-expansion of an intrasellar cyst: A case report. Surg Neurol Int 2020; 11:282. [PMID: 33033644 PMCID: PMC7538794 DOI: 10.25259/sni_212_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/18/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Shodai Yamada
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki,
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki,
| | - Kazuhiro Hirano
- Department of Neurosurgery, Okayama Central Hospital, Okayama, Japan
| | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki,
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Gargallo-Benedicto A, Clemente-Tomás R. Intracraneal hypertension, primary empty sella and papilloedema. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2020; 95:e47-e48. [PMID: 32143846 DOI: 10.1016/j.oftal.2020.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 06/10/2023]
Affiliation(s)
| | - R Clemente-Tomás
- Servicio de Oftalmología, Hospital General Obispo Polanco, Teruel, España
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11
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Byrne N, Kochanski RB, Tajudeen B, Byrne RW. Symptomatic Primary Tethered Optic Chiasm: Technical Case Report. Oper Neurosurg (Hagerstown) 2020; 19:E440-E445. [DOI: 10.1093/ons/opaa093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 02/14/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
Symptomatic tethering of the optic nerves and chiasm is a rare occurrence and has been reported following both surgical and medical treatment of pituitary adenoma. Here we present a case of primary optic chiasm tethering in a patient with empty sella syndrome.
CLINICAL PRESENTATION
The patient was a 61-yr-old female who presented with progressively worsening bitemporal hemianopsia. Magnetic resonance imaging (MRI) brain revealed an empty sella with herniation of the optic chiasm into the sella. The patient underwent an endoscopic, endonasal/trans-sphenoidal approach to the sella, where the optic chiasm was then detethered via lysis of arachnoid adhesions and ultimately buttressed with an abdominal fat graft. Postoperatively, the patient did well with subjective and objective improvements in her visual fields.
CONCLUSION
We report a rare case of primary tethered optic chiasm, which was successfully treated via an endoscopic, endonasal approach with abdominal fat graft harvest.
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Affiliation(s)
- Nika Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Ryan B Kochanski
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Bobby Tajudeen
- Department of Otolaryngology, Rush University Medical Center, Chicago, Illinois
| | - Richard W Byrne
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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12
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Ouma J. Primary empty sella syndrome associated with visual deterioration salvaged by chiasmapexy: Report of a case and discussion of the literature. Surg Neurol Int 2020; 11:48. [PMID: 32257574 PMCID: PMC7110400 DOI: 10.25259/sni_309_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 03/06/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Empty sella syndrome (ESS) is a condition in which there is loss of volume of the pituitary gland, which is the normal constituent of the sella turcica. There may be visual and endocrine deficits associated with this condition, and radiologically, there may be downward prolapse of the optic chiasm. It occurs in a primary ESS, poorly understood form, as well as a secondary ESS form that follows medical or surgical treatment of a pituitary macroadenoma, or else spontaneous hemorrhage into such a tumor. Case Description: A 56-year-old man presenting with deficits of both visual acuity and visual fields in the setting of radiological ESS without associated optic chiasm prolapse is discussed. He underwent endoscopic endonasal chiasmapexy with gradual improvement of his visual function over the following 6 months. Conclusion: ESS is a potentially potent cause of visual deterioration that lends itself to reversal through a relatively simple neurosurgical technique. This case illustrates that actual prolapse of the chiasm is neither a prerequisite for visual deterioration nor its reversal the mechanism of visual improvement after chiasmapexy, raising the question of the mechanisms at play in cases such as this. It confirms the role of chiasmapexy in the management of selected cases of ESS.
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Affiliation(s)
- John Ouma
- Department of Neurosurgery, Medical School, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Guinto G, Nettel B, Hernández E, Gallardo D, Aréchiga N, Mercado M. Osseous Remodeling Technique of the Sella Turcica: A New Surgical Option for Primary Empty Sella Syndrome. World Neurosurg 2019; 126:e953-e958. [DOI: 10.1016/j.wneu.2019.02.195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/30/2022]
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Ishihara E, Toda M, Sasao R, Ozawa H, Saito S, Ogawa K, Yoshida K. Endonasal Chiasmapexy Using Autologous Cartilage/Bone for Empty Sella Syndrome After Cabergoline Therapy for Prolactinoma. World Neurosurg 2018; 121:145-148. [PMID: 30315973 DOI: 10.1016/j.wneu.2018.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/29/2018] [Accepted: 10/01/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Visual field deterioration caused by secondary empty sella after cabergoline therapy for prolactinoma is a rare event. Chiasmapexy is performed to treat empty sella syndrome. Although various materials have been used for the elevation of the optic chasm, the most appropriate material remains to be established. Here, we describe the efficiency of chiasmapexy for empty sella syndrome following dopamine agonist treatment and the utility of septal cartilage and sphenoidal sinus bone as materials for chiasmapexy. CASE DESCRIPTION A 35-year-old male with a history of cabergoline therapy for prolactinoma presented with visual deterioration. His magnetic resonance imaging revealed optic chiasm herniation into the empty sella. Endoscopic endonasal transsphenoidal chiasmapexy was performed using septal cartilage and sphenoidal sinus bone as materials for elevating the chiasm. Visual function improved immediately after operation. CONCLUSIONS Chiasmapexy is an effective surgical method for treating visual deterioration caused by empty sella after cabergoline treatment. Endoscopic endonasal chiasmapexy with septal cartilage and sphenoidal sinus bone is a considerable option because it is minimally invasive and involves decreased risk of infection.
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Affiliation(s)
- Eriko Ishihara
- Department of Neurosurgery, Keio University School of Medicine, Sinjuku-ku, Tokyo, Japan.
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Sinjuku-ku, Tokyo, Japan
| | - Ryota Sasao
- Department of Neurosurgery, Keio University School of Medicine, Sinjuku-ku, Tokyo, Japan
| | - Hiroyuki Ozawa
- Department of Otolaryngology, Keio University School of Medicine, Sinjuku-ku, Tokyo, Japan
| | - Shin Saito
- Department of Otolaryngology, Keio University School of Medicine, Sinjuku-ku, Tokyo, Japan
| | - Kaoru Ogawa
- Department of Otolaryngology, Keio University School of Medicine, Sinjuku-ku, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Sinjuku-ku, Tokyo, Japan
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