Factors influencing postoperative visual improvement in 208 patients with tuberculum sellae meningiomas

OBJECTIVE

Tuberculum sellae meningiomas (TSMs) usually compress the optic nerve and optic chiasma, thus affecting vision. Surgery is an effective means to remove tumors and improve visual outcomes. On a larger scale, this study attempted to further explore and confirm the factors related to postoperative visual outcomes to guide the treatment of TSMs.

METHODS

Data were obtained from 208 patients with TSMs who underwent surgery at our institution between January 2010 and August 2022. Demographics, ophthalmologic examination results, imaging data, extent of resection, radiotherapy status, and surgical approaches were included in the analysis. Univariate and multivariate logistic regressions were used to assess the factors that could lead to favorable visual outcomes.

RESULTS

The median follow-up duration was 63 months, and gross total resection (GTR) was achieved in 174 (83.7%) patients. According to our multivariate logistic regression analysis, age < 60 years (odds ratio [OR] = 0.310; P = 0.007), duration of preoperative visual symptoms (DPVS) < 10 months (OR = 0.495; P = 0.039), tumor size ≤ 27 mm (OR = 0.337; P = 0.002), GTR (OR = 3.834; P = 0.006), and a tumor vertical-to-horizontal dimensional ratio < 1 (OR = 2.593; P = 0.006) were found to be significant independent predictors of favorable visual outcomes.

CONCLUSION

Age, DPVS, tumor size, GTR, and the tumor vertical-to-horizontal dimensional ratio were found to be powerful predictors of favorable visual outcomes. This study may help guide decisions regarding the treatment of TSMs.

[Preoperative Simulation of Endoscopic Endonasal Approach for Craniopharyngiomas or Tuberculum Sellae Meningiomas]

Preoperative simulation for endoscopic endonasal approach(EEA)using computed tomography and magnetic resonance imaging evaluates tumor extension and the relationship between adjacent structure(the pituitary stalk, major vessels, and cranial nerves); therefore, preoperative planning of nasal procedure, skull base bony removal, and cranial base reconstruction are possible. Additionally, three-dimensional(3D)fusion image aids surgeons to visualize intraoperative 3D findings. These preoperative simulations are critical to avoid complications and predict pitfalls perioperatively. However, tumor consistency or adhesion with adjacent structure cannot be predicted but is judged perioperatively, which affects the extent of tumor resection. This manuscript describes important points of preoperative simulation for EEA, especially the transplanum-transtuberculum approach for craniopharyngiomas or tuberculum sellae meningiomas, showing some examples in patients.

Exploring the association between PITX2, third molars agenesis and sella turcica morphology : PITX2, third molars agenesis and sella turcica morphology

OBJECTIVES

PITX2 is required for mammalian development and single nucleotide polymorphisms (SNPs) in this gene could be involved in dental agenesis and sella turcica patterns. Thus, the present study evaluated the association between SNPs in PITX2, third molars agenesis and sella turcica phenotypes.

MATERIALS AND METHODS

The sample consisted of healthy orthodontic German patients with lateral cephalometric radiographs with clearly visualization of the sella turcica, and dental orthopantomograms. The morphological variations of the sella turcica were evaluated using the lateral cephalograms, while third molar agenesis was evaluated using orthopantomograms. DNA isolated from buccal cells was used for genotyping three SNPs in PITX2 (rs3796902, rs1947187, and rs2595110). The analyzes were performed using a significance of 5%. There was no association between third molar agenesis and sella turcica phenotypes (p > 0.05). SNPs in PITX2 were also not associated with third molars agenesis (p > 0.05).

RESULTS

SNPs in PITX2 were associated with sella turcica phenotypes. The rs3796902 was associated with hypertrophic posterior clinoid process (p = 0.013). The rs1947187 and rs2595110 were associated with sella turcica bridge type A (p = 0.013 and p = 0.011, respectively for genotype distribution). Patients that carry the genotypes GG-CC-AG (rs3796902- rs1947187- rs2595110) had 7.2 higher chance to present sella turcica bridge type A (p = 0.002; Odds ratio = 7.2, Confidence interval 95% 2.04-27.04).

CONCLUSIONS

Third molar agenesis was not associated with SNPs in PITX2 and sella turcica phenotypes. SNPs in PITX2 may have an important role in sella turcica pattern.

Intrasellar xanthogranuloma mimicking macroadenoma

Intracranial xanthogranulomas (XGs) have been found at various sites, but xanthogranuloma of the sellar region is extremely rare. We report about a case of sellar XG in a 34-year-old female. Magnetic resonance imaging showed a solid-cystic mass located at the sella turcica. The cystic component was hyperintense on the T1-weighted image (WI) and T2WI. The solid component was hyperintense on T1WI and hypointense on T2WI. There was peripheral enhancement after gadolinium administration. The diagnosis of cystic macroadenoma was considered before surgery. Final diagnosis of XG was confirmed by histopathological examination after surgical resection. Gross total resection of the lesion was achieved using the microscope through endoscopic endonasal transsphenoidal approach. The patient had a good outcome and no symptom of diabetes insipidus, hormonal evaluation did not show any alterations compatible with hypopituitarism and prolactin levels were normal XG should receive diagnostic consideration for the sellar mass lesions with cystic components hyperintense on T1WI and T2WI, solid components hyperintense on T1WI and hypointense on T2WI, and CT without evidence of calcifications. It is important to consider the possibility of XG when pertinent, as it facilitates a proper surgical approach strategy.

Intrasellar Dermoid Cyst: Case Report of a Rare Lesion and Systematic Literature Review Comparing Intrasellar, Suprasellar, and Parasellar Locations

OBJECTIVE

Intracranial dermoid cyst (DC) is a rare benign, slow-growing lesion, most commonly arising along the midline. They can occur in the supratentorial compartment, very rarely involve the sellar region and only exceptionally are intrasellar. The aim of our study is to address the challenges in the diagnosis and management of sellar DCs.

METHODS

We performed a systematic review of sellar DCs, in keeping with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and described an intrasellar DC in a 32-year-old female who presented with bilateral blurring vision.

RESULTS

The review identified 4 intrasellar, 29 suprasellar, and 28 parasellar cases. Intrasellar DCs more likely present with progressive visual impairment and pituitary hormone dysfunctions during the fifth decade of life. Suprasellar and parasellar DCs are typically diagnosed during the third decade of life because of diplopia, ptosis, trigeminal hypoaesthesia/para-esthesia or cyst's rupture. Sellar DCs are typically hypodense on computed tomography scans and contain calcifications. Magnetic resonance imaging features include T1 hyperintensity, T2 heterogeneous intensity, no restriction on diffusion-weighted images, and no contrast enhancement. Surgery is the treatment of choice. Gross total resection is achieved in 60% of intrasellar and 61.9% of suprasellar and parasellar DCs. Early postoperative complications are reported in 40.0%, 16.7%, and 23.8% of intrasellar, suprasellar, and parasellar DCs, respectively.

CONCLUSIONS

Intrasellar DCs are rare lesions typically diagnosed later than suprasellar and parasellar DCs due to their different clinical presentations. However, they should be considered in the differential diagnosis of cystic lesions of the sella, including epidermoid cysts, craniopharyngiomas, Rathke's cleft cysts, and teratomas.

Effect of Optic Canal Opening on Postoperative Visual Acuity in Patients with Tuberculum Sellae Meningiomas

BACKGROUND

 Tuberculum sellae meningiomas (TSMs) account for 5 to 10% of all intracranial meningiomas. They typically invade the optic canal and displace the optic nerve upward and laterally. The transcranial approach has been the standard surgical approach, while the transsphenoidal approach has been proposed for its minimally invasive nature; however, some reservations concerning this approach remain.

METHODS

 From January 2000 to December 2018, a total of 97 patients who were diagnosed with TSM with invasion of the optic canal were enrolled and underwent microsurgery for tumor removal with optic canal opening. A retrospective analysis was performed on the effect of optic canal opening on postoperative visual acuity improvement. The median follow-up was 17.4 months (range: 3-86 months).

RESULTS

 Among the 97 patients with TSM involving the optic canal, optic canal invasion was seen on preoperative imaging in 73 patients and during intraoperative exploration in all patients. In total, 87/97 patients (89.7%) underwent optic canal opening to remove tumors involving the optic canal, and the rate of total macroscopic resection of tumors invading the optic canal was 100%. Among the 10 patients who did not undergo optic canal opening, the rate of total resection of tumors involving the optic canal was 80% (8/10, p < 0.001). There were no deaths or serious complications. The postoperative visual acuity improvement rate was 64.4%, 23.7% maintained the preoperative level, and the visual acuity deteriorated 11.9%.

CONCLUSION

 Intraoperative optic canal opening is the key to total resection of TSMs involving the optic canal and improving postoperative visual acuity.

Computed tomography-based assessment of sphenoid sinus and sella turcica pneumatization analysis: a retrospective study

Background

A preoperative three-dimensional examination of the sphenoid sinus anatomy, its pneumatization pattern, and its relevance to neighboring neurovascular constructions is crucial to preventing possible complications. In this study, the aim was to evaluate the relationship between sphenoid sinus pneumatization types and the sella turcica using computed tomography (CT).

Methods

CT data from 420 patients referred to the Department of Dentomaxillofacial Radiology were evaluated retrospectively. Sella pneumatization types were classified as conchal, presellar, incomplete sellar, and complete sellar, and they were evaluated. Obtained data were evaluated using the IBM SPSS 25.0 (Armonk, New York, USA) package program.

Results

CT images of 420 individuals, including 174 women and 246 men with a mean age of 43.87 ± 17.58 years, were included in the study. When the sella turcica morphologies were evaluated, the most widespread morphological type was irregularity in the posterior part of the dorsum sella, in 51.2% of cases. In addition, a statistically significant correlation was found between the pneumatization of the sphenoid sinus and the morphological types of sella (p < 0.05).

Conclusion

In this research endeavor, the predominant observation comprised the complete sellar sphenoid sinus pneumatization type, exhibiting irregularity in the posterior aspect of the dorsum sella, representing one of the sellar types. Notwithstanding, it is imperative to conduct additional investigations to establish the generalizability of the present study's findings.

Endoscopic Endonasal Approach for Tuberculum Sellae Meningioma: 2-Dimensional Operative Video

INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE

Ideal indications for tuberculum sellae meningiomas (TSM) removal through endoscopic endonasal approach (EEA) are midline tumors (<3.5 cm), possibly with no optic canal invasion and no vessels encasement. The EEA is favored by a wide tuberculm sellae (TS) angle and a deep sella at the sphenoid sinus (SS). 1 Adequate removal of paranasal structures provides a wider surgical corridor ensuring exposure at the suprasellar area and safe instruments manuevrability. 2.

ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT

The endoscopic transtuberculum transplanum approach allows for wide suprasellar intradural exposure. 3 Removal of the supraoptic recess (SOR) provides further lateral extension over the planum sphenoidale (PS) and proper management of dural involvement at the optic canal. 4.

ESSENTIAL STEPS OF THE PROCEDURE

The patients have consented to the procedure. Bone removal starts at the upper sella and TS and is extended anteriorly over the PS and laterally, upon needs, at the SORs. On dural opening, tumor devascularization, dedressing, debulking, and dissection are run. Skull base reconstruction is performed using the 3F technique. 5.

PITFALLS/AVOIDANCE OF COMPLICATIONS

In those cases with vessel encasement, possibility of achieving total resection has to be balanced with risk of vascular injury. 6 Optic canal dural invasion precludes tumor total removal; however, bony decompression is maximal using the EEA. Concerning postoperative cerebrospinal fluid fistula, nowadays the rates have dropped to <2%.

VARIANTS AND INDICATIONS FOR THEIR USE

A wider skull base osteodural opening allows for the removal of selected meningiomas extending to the PS and cribriform plate.

Association between sella turcica bridging and the impaction severity of palatally displaced canines: A retrospective study

INTRODUCTION

This retrospective study aimed to investigate the association between the extent of the bridging and dimensions of sella turcica and the impaction severity of palatally displaced canines. Secondarily, any possible association between skeletal age and gender was evaluated.

METHODS

Panoramic and cephalometric radiographs of 94 patients (63 female, 31 male; 19 pre-peak, 75 post-peak) with palatally displaced canines were evaluated. Sector classification and α angle were used to determine the impaction severity of palatally displaced canines on panoramic radiographs. The distance from the cusp tip of the palatally displaced canines to the occlusal plane (d) and the extent of the bridging and dimensions of the sella turcica were evaluated on cephalometric radiographs.

RESULTS

Sella turcica bridging and dimensions did not vary regarding the impaction severity of palatally displaced canines, but a significant association was found between sella turcica bridging and skeletal age (P = 0.038). Class II (33.3%) and Class III (12.0%) bridging was higher in postpubertal patients. No differences between females and males were detected for the extent of bridging and dimensions of the sella turcica.

CONCLUSIONS

These findings indicate no association between sella turcica bridging and dimensions and the impaction severity of palatally displaced canines. Sella turcica bridging is more frequent in the postpubertal period, whereas gender does not influence sella turcica bridging. More studies are needed to evaluate if the extent of sella turcica bridging may be indicative of severely impacted palatal canines, which in turn would allow for careful monitoring of patients from an early age and for the clinician to take preventive measures.

Morphological types of sella turcica bridging and sella turcica dimensions in relation to palatal canine impaction: a retrospective study

The aim of this study was to determine the relationship between the presence of sella turcica bridging and palatal canine impaction (PCI) using several classification methods. In this retrospective study, lateral cephalometric radiographs of 120 subjects with PCI (43 males, 77 females; mean age 18.8 ± 7.8 years) and 120 controls (44 males, 76 females; mean age 18.1 ± 5.6 years) with complete permanent dentition were examined. The extent of sella turcica bridging was assessed using two different methods, and the types of complete sella turcica bridging were evaluated. The sella turcica dimensions were measured and analyzed using the t-test, and comparison of the presence of sella turcica bridging was performed using the two-tailed Fisher's exact test. The frequency of complete sella turcica bridging was significantly higher in subjects with PCI (18.3%) than in controls (8.3%, p = 0.023) but without significant differences in the occurrence of sella turcica bridging of Type A (ribbon-like fusion) and Type B (extension of clinoid processes). No significant differences in partial bridging were found between patients with PCI and controls according to both methods. The length and the anteroposterior diameter were significantly larger in subjects with PCI and no difference was observed between the groups in the sella turcica depth. Complete sella turcica bridging occurred significantly more frequently in subjects with PCI than in controls. However, the association between partial bridging and PCI was not confirmed, therefore, we do not recommend any classification of partial bridging for clinical practice.

Anatomical features of sella turcica with comprehensive literature review

OBJECTIVE

This study aimed to explore the relationship between skeletal patterns and the frequency of sella turcica bridging in a sample of young Turkish adults in order to provide a better understanding of the relationship between craniofacial morphology and sella turcica abnormalities.

METHODS

A total of 90 individuals aged between 18 and 25 years were examined in this study. The individuals were classified according to their skeletal pattern, specifically Class I, Class II, and Class III. Each group consisted of 15 males and 15 females. The length, depth, and anteroposterior diameter of sella turcica were calculated. The shape and bridging of sella turcica were estimated using lateral cephalometric images. All data were correlated and statistically analyzed according to skeletal patterns, genders, and age.

RESULTS

The mean length, depth, and anteroposterior diameter of sella turcica were 7.02±2.13, 7.56±1.38, and 10.54±1.3 mm in Classes I-III, respectively. There was no significant difference between the dimensions of sella turcica according to gender and age (p˃0.05). The length of sella turcica was larger in Class III, and the depth of sella turcica was larger in Class II individuals (p<0.05). A total of 44.4% of the individuals had normal sella turcica, while the remaining 56.6% had other types of sella turcica. It was determined that 31.1% of the individuals have no calcification, 62.2% had partial calcification, and 6.7% had total calcification.

CONCLUSION

The normal dimensions, shape, and bridging of the sella turcica can be used by the orthodontist for diagnosis, treatment planning, and evaluation of various pathological conditions associated with the sella turcica.

Morphological and Metrical Relationships Between Sphenoid Sinus and Sella Turcica: Possible Applications in Transnasal Transsphenoidal Surgery

INTRODUCTION

Transsphenoidal surgeries imply the risk of intraoperative lesions to the neurovascular structures surrounding the sphenoid sinus (SS). Aim of the present study is to assess the metrical and morphologic relationships existing between SS and sella turcica (ST).

MATERIALS AND METHODS

Two hundred computed tomography-scans of patients were selected. For each patient volumes of SS were calculated from their 3-dimensional models segmented through ITK-SNAP program. Variants of SS in pneumatisation and sellar diameters [antero-posterior (AP) diameter, depth, and length] were evaluated on each computed tomography-scan. Correlations among different measurements were assessed through Spearman test ( P <0.01), whereas associations between sellar parameters and presence of pneumatisation variants were assessed through Mann-Whitney test ( P <0.01).

RESULTS

In males, pneumatization of the greater wings was related to smaller AP diameter ( P <0.01) and depth of ST ( P <0.01), whereas in females lower values of depth were found in patients with pneumatization of the pterygoid processes ( P <0.01). In both sexes, a positive correlation was found between AP diameter and, respectively, length and depth of ST ( P <0.01), together with a negative correlation between volume of SS and depth of ST ( P <0.01). Lastly, in females a positive correlation was found between age and, respectively, length and depth of ST ( P <0.01).

CONCLUSIONS

The present study highlighted new metrical and morphologic relationships between volume and pneumatisation of SS and diameters of ST. Knowledge of these correlations allows to understand more clearly, in the preoperative setting, the surgical working space. Further studies are needed, especially for what concerns the relationship between sellar measurements and age in females.

Demonstration of the inferior intercavernous sinus is closely linked to the extent of pneumatization of the sphenoid sinus: useful information for the pituitary surgeon

PURPOSE

To study the utility of T2-weighted MRI sequences in the identification of the inferior intercavernous sinus (IICS), a potential source of bleeding during transsphenoidal surgery of pituitary adenomas.

METHODS

Pituitary sagittal T1W and coronal T2W MRI sequences were analyzed in 237 consecutive patients, after the exclusion of postoperative MRIs and those revealing an empty sella or a pituitary macroadenoma. Sphenoid sinus pneumatization was defined as incomplete (group 1) if it did not reach the nadir of the sella turcica, as complete (group 2) if it extended beyond the nadir of the sella or asymmetric (group 3), when only one side of the sinus was completely pneumatized.

RESULTS

In Group 2 (70% of the patients), the IICS was rarely visualized on coronal T2W MRI (6/167 patients-3.6%), whereas in Group 1 it was identified in nearly all patients (55/57 patients - 96.5%, p < 0.001). In Group 3, the IICS was only visible above the non-pneumatized part of the sphenoid sinus.

CONCLUSIONS

The IICS can be identified on coronal T2W images in patients with an incompletely pneumatized sphenoid sinus, but very rarely in patients with a totally pneumatized sinus. This information can help to increase awareness among pituitary surgeons of the need to potentially manage IICS bleeding during transsphenoidal surgery in patients with an incompletely pneumatized sphenoid sinus.

Association between sella turcica bridging and impacted maxillary canines

Changes in sella turcica (ST) development may be associated with impaction of the permanent canine teeth. Calcification of the interclinoid ligament, which forms a bridge between the anterior and posterior clinoid processes of the sphenoid bone, has been termed ST bridging. The aim of this study was to evaluate whether an association exists between ST bridging and the presence of impacted maxillary canines (IMCs) in a Brazilian population. In this case-control study, 2 blinded and calibrated examiners measured the length (interclinoidal distance), depth, and diameter of the ST on cephalometric radiographs of 64 adults divided into a case group with IMCs (n = 32) and a control group without IMCs (n = 32). The degree of calcification was established as no (class I), partial (class II), or complete (class III) calcification. A t test was used to compare ST dimensions between the groups, and a chi-square test was used to analyze the association between the degree of calcification and the groups. The association between ST bridging and IMC was estimated by means of logistic regression analysis (α = 0.05). The study findings showed that ST length in the case group was shorter than that in the control group (P = 0.042; t test), and the length was shorter in men than in women (P = 0.038; t test). The ST bridging frequency was higher in the case group (P = 0.03; chi-square test), and there was no difference between men and women. The presence of ST bridging might be associated with increased odds of IMCs (P < 0.01; adjusted odds ratio = 5.92). In this patient sample, the occurrence of IMCs was positively associated with the presence and severity of ST bridging.

Imaging of Sella and Parasellar Region

The sellar and parasellar region is complex, with a unique meningeal, neural, vascular, and bony anatomy. Understanding the imaging anatomy is critical for accurate imaging interpretation. resonance (MR) imaging is the primary modality for pituitary imaging, whereas computed tomography may be used when MR imaging is contraindicated, and provides complementary bony anatomic information. This article reviews embryology and anatomy of the sellar and parasellar region. Imaging appearances of pituitary adenomas, Rathke cleft cysts, meningiomas, craniopharyngiomas, arachnoid cysts, vascular disorders, infectious abnormalities, and pituitary apoplexy are discussed and illustrated.

Sella Turcica Abnormalities, Dental Age and Dental Abnormalities in Polish Children

The frequency of some sella turcica abnormalities on cephalometric radiographs is age related. Chronological age might not overlap with growth; however, no studies could be found on the association between sellar morphology and dental age. Although an association exists between sella turcica bridging and dental abnormalities, no studies have been found correlating sellar abnormalities other than bridging with dental abnormalities. The aim of this study was to find any correlations between sella turcica abnormalities and dental age or dental abnormalities. Methods: Lateral cephalograms and panoramic radiographs of 206 children aged 6–15 years were analyzed for sela turcica abnormalities, Demirijan dental age, and dental abnormalities. Results: The prevalence of dental abnormalities in patients with sela turcica abnormalities was 16.98%, while in those with normal sella, it was 3%. The differences between dental and chronological age were higher in patients with sella turcica abnormalities (p = 0.002). Dental abnormalities were more prevalent (p = 0.001) in patients with sellar abnormalities other than sellar bridging than in those with sellar bridging or normal sella. Conclusions: Sella turcica abnormalities are correlated with delayed dental age. Dental abnormalities are more frequent in patients with sellar abnormalities. Dental abnormalities are less frequent in subjects with sellar bridges compared to those with other sellar abnormalities.

Imaging of the sellar and parasellar regions

Although a wide variety of pathologies can occur in the limited anatomic space within and surrounding the sella turcica only a few are common. This review aims to briefly summarize pituitary and parasellar anatomy and provide a focused description of the imaging features of both common and rare pituitary pathologies. Diagnoses of imaging findings with important implications for clinical management are highlighted. MR is the primary diagnostic modality for evaluation of this anatomic region. CT supplements MR in the evaluation of pathologies involving the bony sella turcica while angiography or nuclear medicine plays a limited clinical role. Despite the wide array of pathologies, imaging and basic clinical history will frequently yield a specific diagnosis or narrow differential. In certain pathologies such as hypophysitis or pituitary hyperplasia, proper imaging interpretation may obviate the need for surgical biopsy or resection. The two key elements to diagnosis in the pituitary region are localization of the abnormality and recognition of characteristic imaging features for different pathologies. Localization is particularly important in separating parasellar masses such as meningiomas, skull base tumors, carotid aneurysms, craniopharyngiomas, or sphenoid sinus tumors from pituitary masses. Imaging features are often variable and in some cases such as craniopharyngioma or epidermoid, can be almost pathognomonic. In cases of neoplastic pathology, imaging both provides diagnostic information and guides planning of surgical biopsy or resection. In most cases, biopsy or resection is performed though a trans-sphenoidal endoscopic route, and identifying invasion or the suprasellar cistern, skull base, or cavernous sinuses is critical.

Sella Turcica Morphology on Cephalometric Radiographs and Dental Abnormalities-Is There Any Association?-Systematic Review

Background: The sella turcica is a saddle-like structure in the middle cranial fossa on the intracranial surface of the sphenoid bone, visible on lateral cephalograms routinely conducted for orthodontic diagnosis. The development of facial structures follows similar traits to the sella turcica: glandular anomalies may be associated with functional disorders, e.g., altered hormonal levels, thus influencing dental development. The aim of this study is to find out if there is any association between the morphology of the sella turcica on cephalometric radiographs and the presence of dental abnormalities. (2) Methods: The search was conducted on 27 January 2021 in four search engines: Medline (PubMed Central), Scopus, Web of Science, Embase. The keywords used in the search strategy were as follows: “sella turcica” AND (“dental abnormalities” OR “dental anomalies” OR “malocclusion”). Since all the studies finally included were retrospective case–control studies, the Newcastle–Ottawa Quality Assessment Form for Case–Control Studies was applied. (3) Results: The search strategy identified 465 articles: 289 from PubMed, 121 from Scopus, 32 from Web of Science and 23 from Embase. Finally, 10 full-text papers were included into qualitative analysis. (4) Conclusions: Sella turcica bridging is very frequent among orthodontic patients. A clear association exists between dental abnormalities and sella turcica bridging.

Sella Turcica Area and Location of Point Sella in Cephalograms Acquired with Simulated Patient Head Movements

AIM AND OBJECTIVE

This study assesses changes in the sella turcica area (STA) and location of the cephalometric point sella (S) on lateral cephalograms acquired by charge-coupled device (CCD)-based cephalostats with and without simulated patient head movements.

MATERIALS AND METHODS

A real skull was placed on a robot, able to simulate four head movements (anteroposterior translation/lifting/nodding/lateral rotation) at three distances (0.75/1.5/3 mm) and two patterns (returning to 0.5 mm away from the start position/staying at maximum movement excursion). Two ProMax-2D cephalostats (Dimax-3, D-3 or Dimax-4, D-4), and an Orthophos-SL cephalostat (ORT) acquired cephalograms during the predetermined movements ("cases," 48 images/unit) and without movement ("controls," 24 images/unit). Three observers manually traced the contour of sella turcica and marked point sella using a computer mouse. STA was calculated in pixels² by dedicated software based on the tracing. S was defined by its x and y coordinates recorded by the same software in pixels. Ten percent of the images were assessed twice. The difference between cases and controls (case minus control) for the STA and S (namely Diff-STA and Diff-S) was calculated and assessed through descriptive statistics.

RESULTS

Inter- and intraobserver agreement ranged from moderate to good for STA and S. Diff-STA ranged from -42.5 to 12.9% (D-3), -15.3 to 9.6% (D-4), and -25.3 to 39.9% (ORT). Diff-S was represented up to 50% (D-3), 134% (D-4), and 103% (ORT) of the mean sella turcica diameter in control images.

CONCLUSION

Simulated head movements caused significant distortion in lateral cephalograms acquired by CCD-based cephalostats, as seen from STA and S alterations, depending on the cephalostat.

CLINICAL SIGNIFICANCE

Patient-related errors, including patient motion artifacts, are influential factors for the reliability of cephalometric tracing.

Morphometric evaluation of cranial base and sella turcica in patients with bilateral agenesis of maxillary lateral incisors

The aim of this paper is to evaluate the dimensions and morphology of cranial base and sella turcica in patients with bilateral agenesis of maxillary lateral incisors (BMLI). This retrospective study was conducted on lateral cephalometric radiographs of 34 female patients with BMLI (17.69 ± 2.96 years) and 34 female patients with complete dentation and skeletal Class 1 relationship serving as a control group (17.22 ± 2.2 years). Basicranial and maxillomandibular variables together with linear dimensions and morphology of sella turcica were evaluated. Differences between groups were analyzed by Student's t test for parametric variables and Mann-Whitney U test for nonparametric variables. Chi-square test followed by post hoc test with Bonferroni correction was used for categoric variables (p < 0.05). When compared to control group, N-S-Se angle was less negative, dimensions between Ba-Se, N-Ba, and N-Ar were larger, and SNA angle was smaller in BMLI group. There were no significant differences between groups regarding the linear dimensions of sella turcica. However, variations in sella turcica morphology were more frequent in BMLI group (n = 17; 50%) when compared to control group (n = 2; 5.8%). The most common morphologic variations in BMLI group were oblique anterior wall (20.6%) and irregularity (notching) in the posterior part of sella turcica (14.7%). The present study showed a statistically significant relationship between the presence of BMLI with some craniofacial parameters and morphological variations of sella turcica. This information may be useful as an additional and early diagnostic tool for BMLI and to highlight the possible links to its development.

Successful pregnancy after operation in an infertile woman caused by luteinizing hormone-secreting pituitary adenoma: case report and literature review

BACKGROUND

Functional gonadotroph adenomas (FGAs) are rare adenomas that most commonly secrete FSH. However, solitary LH-secreting pituitary adenomas are unusual.

CASE PRESENTATION

A 30-year-old woman with elevated LH and normal FSH presented with inability to conceive. An MRI revealed an enlarged sella turcica and an intrasellar mass. Treatment with transsphenoidal resection led to normalization of LH and estradiol, as well as successful pregnancy. And we reviewed 6 cases of LH-secreting pituitary adenomas from 1981 to 2020.

CONCLUSIONS

Our case is unique because of the LH-secreting pituitary adenoma without FSH hypersecretion. This case indicates that pituitary adenoma should be considered when other diseases causing infertility have been excluded.

Basal Ganglia Germ Cell Tumors With or Without Sellar Involvement: A Long-Term Follow-Up in a Single Medical Center and a Systematic Literature Review

BACKGROUND

Basal ganglia germ cell tumors (BGGCTs) represent an extremely rare subset of tumors about which little is known. Some patients suffer from tumor dissemination, such as sellar involvement. This study aimed to evaluate the independent prognostic risk factors of patients with BGGCTs with or without sellar involvement.

METHODS

Sixteen patients were diagnosed with BGGCTs at Peking Union Medical College Hospital from January 2000 to December 2020. A literature review was performed on the online databases Medline and PubMed, and 76 cases in the 19 retrieved articles were identified at the same time. The data regarding biochemical tests, radiological examinations, and outcomes during follow-up were analyzed.

RESULTS

Of 92 patients in this study, seven patients were clinically diagnosed as germinomas, with the remaining 85 patients receiving surgery. Fifty-two patients suffered from multifocal lesions or tumor dissemination. The patients with BGGCTs demonstrated a significant male predilection. The patients with delayed diagnosis more likely had cognitive disturbance (p = 0.028), mental disturbance (p = 0.047), and diabetes insipidus (p = 0.02). Multivariate analysis demonstrated that the independent poor prognostic risk factors of patients with BGGCTs were delayed diagnosis [odd ratio (OR) 2.33; 95% CI 1.02-5.31], focal radiotherapy (OR 4.00; 95% CI 1.69-9.49), and non-pure germinoma (OR 4.64; 95% CI 1.76-12.22).

CONCLUSIONS

The delayed diagnosis, focal radiotherapy, and non-pure germinoma were associated with a poorer prognosis for patients with BGGCTs with or without sellar involvement.

Imaging characteristics of Intrasellar cavernous hemangioma: A case report

RATIONALE

Intrasellar cavernous hemangiomas (ICHs) are rare vascular lesions that arise in the sellar region. ICHs are usually misdiagnosed and treated as pituitary adenomas. Therefore, a preoperative diagnosis is particularly important, especially when the goal is complete resection.

PATIENT CONCERNS

A 55-year-old woman presented with a 1-month history of intermittent dizziness. Magnetic resonance imaging (MRI) revealed a well-demarcated abnormal ellipsoid signal in the sellar region (size: 2.7 cm × 1.7 cm), with a mulberry-like enhancement after gadolinium injection. Computed tomography revealed an intrasellar mass without calcification that extended into the left cavernous sinus and was faintly contrast-enhanced. Angiography revealed a tumor with mildly delayed staining fed by the C5 segment of the right internal carotid artery.

DIAGNOSIS

An intrasellar cavernous hemangioma based on neuroradiological examinations.

INTERVENTIONS

The patient underwent surgery with an endoscopic endonasal transsphenoidal approach to debulk the lesion and obtain tissue for the pathological diagnosis.

OUTCOMES

Blood spurting was observed after puncture, and the capsule was stained blue. Lesion removal was stopped, and the patient underwent gamma knife surgery 1 week later. She remained in good condition during the follow-up.

LESSONS

Sponge-like or mulberry-like lesions can be identified on MRI after gadolinium injection and can facilitate a preoperative diagnosis of ICH. Currently, surgical debulking with cranial nerve decompression during the acute stage and subsequent gamma knife radiosurgery are considered to be a safe and effective treatment.

Reappraisal of haemorrhagic suprasellar pilocytic astrocytoma during adulthood

Pilocytic astrocytomas comprise the most common central nervous system tumour during childhood and have an excellent response to surgical treatment in this population. The tumour incidence decreases with age, whereas more aggressive behaviour tends to increase. Haemorrhage as a presenting feature of pilocytic astrocytomas is a rare phenomenon, especially in the adult population. We present a case of a 55-year-old patient with progressive headaches and dizziness. MRI confirmed a sellar and predominantly retrochiasmal suprasellar lesion with heterogeneous signal, enhancement and blood products. Management via transsphenoidal approach was performed, and histopathology revealed the unexpected diagnosis of haemorrhagic pilocytic astrocytoma. Haemorrhagic pilocytic astrocytoma is an infrequent entity in the adult population and it is essential to recognise the peculiarities regarding diagnostic evaluation and management, which differ from the paediatric population. During adulthood, this tumour carries an overall unfavourable prognosis, with higher rates of progression and recurrence.

Xanthogranuloma of the sellar region: A case report

RATIONALE

Xanthogranuloma of the sellar region is exceedingly rare, and described in only a handful of case reports. Herein, we present a case of xanthogranuloma of the sellar region to improve our knowledge for the diagnosis and management of this unusual disease.

PATIENT CONCERNS

A 50-year-old female presented with the symptoms of intermittent vomiting, occasional head discomfort, and diabetes insipidus of 1 month duration.

DIAGNOSES

Magnetic resonance imaging showed a large well-defined, vase-like, heterogeneous mass in the sellar region. The lesion showed mixed signal with hierarchical signal presentation. Fluid-fluid level sign can be found within the lesion. The upper part of the lesion was hyperintense, and the lower part was hypointense on both T1-weighted images and T2-weighted images. The lesion showed no enhancement following the intravenous administration of gadolinium. The normal pituitary tissue was not clearly visible. Optic chiasm was compressed and displaced by the lesion. Initial diagnosis of pituitary macroadenoma with hemorrhage in the sellar region was made before surgery. Final diagnosis of sellar xanthogranuloma was confirmed by histopathological examination after surgical resection.

INTERVENTIONS

Gross total resection of the lesion was achieved using the microscope through endonasal transsphenoidal approach.

OUTCOMES

The patient recovered well with improved binocular vision and no symptom of diabetes insipidus, and was discharged 5 days after operation.

LESSONS

Sellar xanthogranuloma should receive diagnostic consideration for the lesion that is a heterogeneously mixed mass with a degree of T1-weighted images hyperintense in the sellar region.

Sphenoid sinus agenesis and sella turcica hypoplasia: very rare cases of two brothers with Hamamy syndrome

Hamamy syndrome (HS) is an autosomal recessive syndrome with a genetic origin that is very rarely observed. The syndrome with craniofacial dysmorphisms, including midface prominence, severe telecanthus, sparse lateral eyebrows, protruding ears, fronto-nasal abnormalities, lacrimal-salivary apparatus agenesis, thin upper vermillion border, myopia, mental retardation, sensorineural hearing impairment, congenital heart anomalies with intraventricular conduction delay, hypochromic microcytic anaemia and skeletal abnormalities of the long bones with recurrent fractures. In this paper, we report a case of two brothers diagnosed with HS at the ages of 25 and 18 years, visited out clinic at different times due to dental reasons. In the radiological examinations, it was observed that both brothers have sphenoid sinuses agenesia, and their sella turcica were smaller than normal. HS may be observed very rarely, and it should be kept in mind that, in addition to various symptoms, it may also cause sphenoid sinus agenesis and sella turcica hypoplasia as shown for the first time in this case report.

Associations among palatal impaction of canine, sella turcica bridging, and ponticulus posticus (atlas arcuate foramen)

INTRODUCTION

The palatal impaction of canine (PIC) can be predicted by some head and neck skeletal anomalies or variants. Since studies on this regard (especially vertebral anomalies) are scarce, this study was conducted.

METHODS

This case-control study was done on 46 PIC orthodontic patients (34 females, 12 males) and 46 control orthodontic patients (36 females, 10 males). The diagnosis of PIC was done on lateral cephalographs and panoramic radiographs. On cephalographs, sella turcica bridging (occurrence and severity) and ponticulus posticus (occurrence and severity) were assessed. Associations between PIC, sella bridging, and ponticulus posticus were examined statistically (α = 0.05, β ≤ 0.2).

RESULTS

Cases' and controls' mean ages were 17.7 ± 4.0 and 17.4 ± 3.5, respectively. Of the case subjects, 22, 22, and 2 had respectively types I (normal), II, and III of sella bridging, while these numbers were 34, 12, and 0 in controls (chi-square P = 0.023 for severity, 0.010 for occurrence). Ponticulus posticus was observed in 28 cases (7 completed) and 17 controls (6 completed, P = 0.022 for occurrence, 0.056 for severity). Sella bridging was not associated with ponticulus posticus (Spearman P = 0.150). According to binary logistic regression, sella bridging can increase the odds of palatal canine impaction for OR = 2.8 times, while ponticulus posticus for OR = 2.6. Age and sex did not affect sella bridging or ponticulus posticus.

CONCLUSIONS

Both sella bridging and ponticulus posticus can predict an increased rate of PIC for more than 2.5 times.

Suprasellar pituitary adenomas: a 10-year experience in a single tertiary medical center and a literature review

BACKGROUND

Suprasellar pituitary adenomas (SPAs) are a special type of pituitary adenoma. Although dozens of SPA cases have been reported, the exact definition and the characteristics of SPA have not been exhaustively discussed before.

METHODS

In a retrospective electronic medical records review, 13 patients with SPA were identified in our hospital between January 2010 and December 2019. A literature review was performed by searching the online database PubMed, and 39 cases conformed to the criteria based on the previous literature. Data regarding clinical symptoms, imaging manifestations, surgical information and follow-ups were analyzed.

RESULTS

The mean age at diagnosis of 52 patients with SPA was 36.73 years, and most of the patients were female (61.5%). The most common hormone-secreting subtypes of SPA were nonfunctioning (36.5%) and ACTH-secreting (34.6%) SPA. Macroadenomas (68.9%) were more common than microadenomas (31.1%). The origins of the SPAs included the intrasellar pituitary gland (type I), the subdiaphragmatic (type IIa) and supradiaphragmatic (type IIb) part of the pituitary stalk, and the suprasellar peri-infundibular region (type III). The most common anatomic subtype of SPA was type III, and type IIb was also common. The most common presentations of SPA were visual symptoms, especially for type III SPA. In addition, 64.7% and 73.1% of type IIb and III SPAs, respectively, were suspected to be of suprasellar origin based on presurgical imaging examination. Patients with tumors of suspected suprasellar origin were more likely to receive transcranial surgery (TCS) initially than those with tumors of suspected intrasellar origin (70.6% vs. 22.2%, p = 0.0013). The intact rate for the pituitary stalk after surgery for type II SPA was lower than that for type I and III SPA (52.6% vs. 92.6%, p = 0.0036). More patients with type II SPA experienced postoperative central diabetes insipidus (CDI) than those with type I and III SPA (57.9% vs. 11.1%, p = 0.0011). There was no significant difference in the incidence of postoperative CDI between transsphenoidal surgery (TSS) and TCS (p = 0.1304). Nine patients in our hospital received extended endoscopic TSS; only one experienced tumor recurrence, and no severe complications occurred after surgery.

CONCLUSIONS

SPAs could be defined as pituitary adenomas completely or partially located in the suprasellar region. There were both similarities and differences among the different anatomic subtypes of SPA. For patients who were suspected of having SPAs, visual field tests, pituitary hormone evaluation and MRI were necessary. Because imaging examination is not a reliable method, surgery is the only way to confirm the tumor origin. Extended endoscopic TSS might be a safe and efficient approach to remove these tumors, but more studies are needed to verify this conclusion. For type II SPA, the pituitary stalk should be carefully protected during surgery, and postoperative CDI should be monitored.

Risk Factors for Patient-Reported Olfactory Dysfunction After Endoscopic Transsphenoidal Hypophysectomy

Importance

Iatrogenic olfactory dysfunction after endoscopic transsphenoidal hypophysectomy (ETSH) is an overlooked complication without elucidated risk factors.

Objective

To assess the independent prognostic role of demographic, comorbidity, cephalometric, intraoperative, histological, and postoperative parameters in patient-reported postoperative olfactory dysfunction, and to explore the association between anatomical measurements of the skull base and sinonasal cavity and postoperative olfactory dysfunction.

Design, Setting, and Participants

This retrospective cohort study in a tertiary care medical center enrolled consecutive patients with primary sellar lesions who underwent ETSH between January 1, 2015, and January 31, 2019. Patients were excluded if they underwent multiple sinonasal surgical procedures, presented with a sellar malignant neoplasm, required an expanded transsphenoidal approach, had nasal polyposis or a neurodegenerative disease, or sustained traumatic brain injury. After undergoing medical record review and telephone screening, patients were asked to participate in a 3-item telephone survey.

Main Outcomes and Measures

The primary outcome was the Clinical Global Impressions change in smell rating, a validated transitional patient-reported outcome measure. Patients rated their change in smell before and after ETSH on a 7-point Likert scale, with the following response options: (1) much better, (2) somewhat better, (3) slightly better, (4) neither better nor worse, (5) slightly worse, (6) somewhat worse, or (7) much worse. Responses of slightly worse, somewhat worse, and much worse were surrogates for postoperative olfactory dysfunction status. Patient medical records, preoperative imaging scans, operative notes, and pathology reports were reviewed.

Results

Of the 147 patients (mean [SD] age, 54 [15] years; 79 women [54%]) who responded to the telephone survey, 42 (29%) reported olfactory dysfunction after ETSH. Median (interquartile range [IQR]) time between the ETSH completion and survey response was 31.1 (21-43) months. On multivariable analysis, abdominal fat grafting (adjusted relative risk [aRR], 2.95; 95% CI, 1.89-4.60) was associated with postoperative olfactory dysfunction, whereas smoking history (aRR, 1.54; 95% CI, 0.95-2.51) demonstrated a clinically meaningful but imprecise effect size. A more obtuse angle between the planum sphenoidale and face of the sella turcica on sagittal imaging was protective (aRR, 0.98; 95% CI, 0.96-0.99). Increased number of months after the ETSH was associated with patient-reported normosmia (aRR, 0.93; 95% CI, 0.91-0.95). In contrast, other comorbidities; intraoperative variables such as turbinate resection, nasoseptal flap, and mucosal or bone grafting; histological variables such as pathology and proliferative index; and postoperative variables such as adjuvant radiotherapy were not associated with postoperative olfactory dysfunction.

Conclusions and Relevance

This study found that abdominal fat grafting, acute skull base angle, and smoking history appeared to be clinically significant risk factors for patient-reported postoperative olfactory dysfunction. Increased time after ETSH may be associated with better olfactory outcomes.

Collision sellar lesions: coexistence of pituitary adenoma and Rathke cleft cyst-a single-center experience

PURPOSE

Collision sellar lesions represent the coexistence of distinct histopathological lesions found in the sella turcica. They are uncommon entities and have mainly been reported as pituitary adenoma (PA) associated to Rathke cleft cyst (RCC). Pre- and perioperative diagnosis is difficult, since most of the cases appear clinically, radiologically, and macroscopically as solitary cystic sellar lesion.

METHODS

A retrospective study of histological reports from patients operated for PA from 2013 to 2018 in a single neurosurgery reference center was performed. Patients who also exhibited RCC in the histological sections were included. Clinical and biochemical data were collected from medical files. MRI scans and histopathological slides were also reviewed.

RESULTS

Among 554 PA, five patients (0.9%) presented the association of PA and RCC. At diagnosis, patients had median age of 60 years (33-78) with, at least, one pituitary dysfunction, and visual field loss and/or headache. There was a female predominance (n = 3). All patients had nonfunctioning PA. MRI studies showed a predominantly cystic lesion and were unable to distinguish both lesions. The definitive diagnosis was made by histopathology.

CONCLUSION

The association of PA and RCC is extremely rare. On MRI, they appear as a solid-cystic or cystic sellar tumors. RCC can rupture causing granulomatous reaction with cholesterol crystal formation, which can be mistaken for craniopharyngiomas during surgery. Therefore, collision sellar lesion must be included in the differential diagnosis of cystic sellar lesions. The definitive diagnosis is made by histological study.

Complications of stereotactic biopsy of lesions in the sellar region, pineal gland, and brainstem: A retrospective, single-center study

Stereotactic biopsy (STB) is commonly used in the pathological diagnosis of intracranial lesions. The associated complication and mortality rates are low, but few reports with large sample sizes have assessed the complications of STB for lesions in the brain midline.To evaluate the complications of STB of lesions in the sellar region, pineal region, and brainstem.This was a retrospective analysis of patients who underwent STB of lesions in the sellar region, pineal region, and brainstem at the Neurosurgery Department, Sixth Medical Center, PLA General Hospital, China, between January 2015 and December 2017. The rates of and possible reasons for surgical complications (including bleeding) and mortality were analyzed.A total of 145 patients underwent STB of midline brain lesions, including 16 (11.0%) in the sellar region, 18 (12.4%) in the pineal region, and 111 (76.6%) in the brainstem. Successful biopsy of the sellar region, pineal region, and brainstem was achieved in 16/16 (100%), 18/18 (100%), and 107/111 (96.4%) patients, respectively. There were no complications following STB of lesion in the sellar or pineal regions. Complications occurred in 17/111 patients (15.3%) during/after brainstem biopsy, three of whom died (2.7%). The main clinical manifestations were facioplegia, facial pain, changes in blood pressure and heart rate, and difficulty breathing.STB of lesions in the sellar region, pineal region, and brainstem had a high success rate, but mortality was 2.7%. The occurrence of complications (15.3%) was closely related to the anatomical and functional characteristics of the region biopsied.

Pituitary Adenoma: A review of existing classification systems based on anatomic extension and invasion

Pituitary adenomas are common, benign tumours, that can be classified in many ways including their functionality, size and anatomical extension. Historically, larger more invasive adenomas with extension into parasellar regions were deemd untreatable. However, with increasing operative sophistication, and more precise and effective radiation options; it is no longer the case, and therefore it becomes even more important for a comprehensive classification system for these tumours. Herein, the authors present an updated review on the available classification systems for large pituitary adenomas, based on their anatomic extension and invasion of adjacent anatomic structures.

Intrasellar symptomatic salivary gland: case series and literature review

PURPOSE

Ectopic salivary glands have been found in both extracranial and intracranial locations, however, intrasellar symptomatic salivary gland is extremely rare and its clinical manifestation, radiological characteristics and outcome have not been systematically studied. Here we present a case series of intrasellar symptomatic salivary gland and perform a literature review to better characterize this disease.

METHODS

We retrospectively reviewed the data of three patients with intrasellar symptomatic salivary gland from our institutional and other cases available in literatures. Information for sex, age at diagnosis, clinical symptoms, radiological features, treatment strategy and prognosis were recorded.

RESULTS

A total of 11 cases (including our own) were identified. There were three men and eight women, with an average age at diagnosis of 28.3 years. The peak incidence was in the second and the third decade (72.7% of all cases). The most common symptom was headache (81.8% of all patients). About 63.6% patients had one or more abnormal hormone levels, and prolactin was likely the most vulnerable hormone. The radiological appearances of intrasellar salivary gland were various, and four cases mimicked pituitary adenoma radiologically. All patients underwent transsphenoidal surgery with no mortality.

CONCLUSION

Although intrasellar symptomatic salivary gland is rare, it should be considered in the differential diagnosis of intrasellar lesions. Preoperative diagnosis is challenging since it mimics pituitary neoplasm in clinical and radiological manifestations, and confirmation for this disease could only be conducted through pathological examination. Transsphenoidal surgical resection is the preferred therapy and the patient prognosis is usually good.

Nonneuroendocrine Neoplasms of the Pituitary Region

CONTEXT

Although most sellar lesions are related to pituitary adenomas, the region gives rise to a variety of neoplasms that can be associated with substantial morbidity and/or mortality.

DESIGN

Information from reviews and guidelines of relevant societies dealing with such neoplasms, as well as articles that have provided new developments that made important contributions to their pathogenesis and treatment up to 2018, were obtained: public indexes such as PubMed/MEDLINE were used with the relevant search items.

RESULTS

Sellar neoplasms have a worse outcome than pituitary adenomas that is related not only to their natural history but also to side effects of therapies and evolving endocrine and/or hypothalamic deficiencies. Recent imaging advances have established the radiological fingerprint of some of these neoplasms, and several chromosomal aberrations have also been identified. Although established approaches along with new surgical and radiotherapeutic approaches remain the main treatment modalities, recent evidence has provided insight into their molecular pathogenesis involving, other than chemotherapy, treatments with targeted agents as in gliomas and craniopharyngiomas bearing BRAF mutations. Development of predictive markers of recurrences may also identify high-risk patients, including proliferative markers and expression of the progesterone receptor in meningiomas, and lead to less aggressive surgery. Owing to the rarity and complexity of these neoplasms, patients should be managed in dedicated centers.

CONCLUSIONS

The diagnosis and management of sellar neoplasms necessitate a multidisciplinary approach. Following evolving recent advances in their diagnosis and therapy, such a multidisciplinary approach needs to be extended to establish evidence-based diagnostic and management plans.

A Rare High-Grade Glioma with a Histone H3 K27M Mutation in the Hypothalamus of an Adult Patient

BACKGROUND

Diffuse midline glioma H3 K27M mutant is a new tumor entity described in the revised 2016 World Health Organization classification. It is most frequently observed in children and develops in midline structures, including the brainstem, thalamus, and spine. We describe a rare diffuse midline glioma with an H3 K27M mutation arising in the hypothalamus of an adult.

CASE DESCRIPTION

A 27-year-old woman was admitted to our department complaining of amenorrhea, polydipsia, and diuresis for the previous 3 months, and headache and lethargy for approximately 10 days. Computed tomography scan showed an oval isodense solid mass extending from the pituitary toward the suprasellar cistern. A gadolinium-enhanced magnetic resonance imaging (MRI) showed a strongly heterogeneous enhanced solid lesion and nonenhanced cystic lesion. The patient underwent surgery and chemoradiotherapy with temozolomide. Histologic and immunohistochemical analyses revealed H3 K27M-mutant diffuse midline glioma. The patient underwent another resection for a recurrent tumor 5 months after the first surgery. Three months after the second operation, the patient relapsed, with MRI revealing spinal cord and meningeal metastases; she died shortly afterward.

CONCLUSIONS

Diffuse midline glioma with an H3 K27M mutation occurring in the hypothalamus of an adult is rare but should be considered in differential diagnoses. Because histone H3 K27M mutations are associated with aggressive clinical behavior and poor prognosis, molecular analyses should be used to determine the clinical and histopathologic features of such tumors. This will contribute to developing targeted drugs and gene therapy going forward.

Differentiation of postoperative changes and residual tumors in dynamic contrast-enhanced sella MRI after transsphenoidal resection of pituitary adenoma

To establish magnetic resonance imaging (MRI) features that differentiate residual tumors from postoperative surgical changes following the transsphenoidal approach of a pituitary adenoma.We analyzed residual enhancements at the tumor bed in 52 patients who underwent dynamic contrast-enhanced sella MRI within 48 hours after surgery and at 6 to 28 months. Patients were divided into 2 groups defined by either peripheral or nodular enhancement patterns. For each group, we measured the maximum thickness of the residual enhancing portion and compared differences in the residual tumor and postoperative changes.Among the tumors examined in the 52 patients, 19 residual tumors showed nodular (n = 16) and peripheral (n = 3) enhancement patterns, and 33 postoperative changes showed nodular (n = 3) and peripheral (n = 30) enhancement patterns. The mean residual tumor thickness was 7.1 mm (range, 2.9-16.8 mm) and 1.9 mm (range, 1.0-7.4 mm) in the postoperative change. Receiver operating characteristic curve analysis revealed that a 3.9-mm thickness was associated with 89% sensitivity, 97% specificity, and 94% accuracy for diagnosis of residual tumor.On immediate postoperative MRI, residual enhancement with greater than 3.9-mm thickness and nodular pattern suggest residual pituitary adenoma tumor.

Association Between Variations In Sella Turcica Dimensions And Morphology And Skeletal Malocclusions

BACKGROUND

The growth of sella turcica is completed early in life, therefore it can be used as a stable landmark for the prediction of future skeletal malocclusions. This early diagnosis may help in planning less complicated treatment modalities. Therefore, this study aimed to evaluate the relationship between sella turcica dimensions and morphology with various skeletal patterns.

METHODS

A cross sectional study was conducted using the pre-treatment cephalograms of 180 subjects aged 13-19 years. The subjects were divided into two groups based on skeletal patterns. The dimensions of sella turcica and skeletal patterns were digitally measured using View Pro-X software. One-way ANOVA was applied to compare sella turcica dimensions among skeletal patterns. Sella dimensions and vertical growth patterns were compared using Post-hoc Tukey test. Chi-square test was applied to compare sella morphology among malocclusion groups. Results were taken as statistically significant at p-value of ≤0.05.

RESULTS

Sella dimensions showed insignificant differences among sagittal groups whereas, significant differences were found for sella length (p≤0.02) and depth (p≤0.03) among the vertical groups. Multiple comparisons showed significant differences between sella length (p≤0.03) and diameter (p≤0.04) between normodivergent versus hyperdivergent groups. Moreover, significant differences were found in the sella turcica morphology among sagittal malocclusion (p≤0.03).

CONCLUSIONS

Increased dimensions of sella turcica were associated with hyperdivergent growth pattern. Bridging of the sella turcica was found to be prevalent in class III malocclusion.

Posterior pituitary tumours: the spectrum of a unique entity. A clinical and histological study of a large case series

PURPOSE

In 2017, the WHO established that pituicytoma, granular cell tumour (GCT) and spindle cell oncocytoma (SCO) are posterior pituitary tumours (PPT). Recent data suggests that these tumours probably arise from the pituicytes and may constitute a spectrum of a unique histopathological entity. Our aim is to report the clinical findings and surgical outcomes of 16 patients with PPT. We also evaluated the tissue specimens available in light of current knowledge.

METHOD

Cross-sectional study with retrospective data.

RESULTS

PPT were 7 pituicytomas, 3 GCT and 6 SCO. Patients mean age was 55 years old and 75% were female. Basal hormonal study showed hyperprolactinemia (43.7%) and hypopituitarism (37.5%). There was no case of diabetes insipidus (DI). MRI showed sellar/suprasellar masses with mean size of 19.7mm. PPT was not suspected in any patient. Fifteen patients underwent surgery and complications were common: 20% had perioperative bleeding (one patient died because of a massive haemorrhage), 57.1% hypopituitarism, 35.7% permanent DI and 21.4% underwent a second surgery. Pathological findings shown positivity for thyroid transcription factor 1, vimentin and negativity for cytokeratin and chromogranin A in all specimens evaluated. S100 protein was positive in 88.8% of tumours. Ki67 was ≥ 3% in 66.6% and ranged from 4-7% in SCO.

CONCLUSION

PPT have similar histology, clinical features and are frequently misdiagnosed as nonfunctioning pituitary tumours. However, post-surgical complications including haemorrhage are common. A high clinical suspicion is needed to presume the diagnosis prior surgery and diminish the high morbidity of these tumours.

Radiological analysis of the sella turcica and its correlations with body mass index in a North Indian population

OBJECTIVES

The sella turcica is an important component situated in the mid-third of the cranial fossa. Knowledge about its normal morphologies and dimensions may play a crucial role in diagnosing underlying pathologies. The present study aimed to analyze the principal morphological shapes of the sella turcica, measure its linear dimensions, and determine whether any correlations exist between its dimensions and body mass index (BMI) in subjects in a North Indian population.

METHODS

The study was conducted on 100 subjects (50 men; 50 women) who underwent cone-beam computed tomography scans at our Oral Medicine and Radiology Department. The subjects had an age range of 20-60 years. The morphology of the sella turcica was examined according to age and various measurements were taken to determine its size. Possible correlations between the dimensions of the sella turcica and BMI were evaluated by statistical analysis.

RESULTS

In the present study, 69% of the subjects had a normal morphology. No uniform increases in length, width, and depth of the sella turcica were observed with aging. When Pearson correlation coefficients were calculated, no strong correlations were found between the dimensions of the sella turcica and BMI. A mild correlation was seen between the length and width of the sella turcica.

CONCLUSION

No significant correlations were found between the dimensions of the sella turcica and BMI in the present study. These findings may have arisen through the small sample size, and thus further studies with larger groups of subjects are warranted.

Degrees of Diaphragma Sellae Descent during Transsphenoidal Pituitary Adenoma Resection: Predictive Factors and Effect on Outcome

This study is aimed to classify degrees of diaphragma sellae (DS) descent into sella turcica according to the surgical field block caused by the descent and to construct predictive imaging criteria for the degree of descent, and in addition, to determine whether there is any correlation between the degree of DS descent and the operative outcome (in the form of cerebrospinal fluid leak and/or presence of residual tumor). Totally, 72 patients were enrolled in our study. Their clinical and radiological data as well as the high definition videos of operations were retrospectively reviewed. The degree of DS descent during the operation was classified into five degrees according to surgical field block caused by the descent. We investigated the correlation between these five degrees and the clinical findings, radiological findings as well as the surgical outcomes. We found that the most important determining factors of DS descent degree were the volume and the height of the tumor portion above diaphragma opening. On the other hand, the total tumor volume, the maximum tumor height and the morphological pattern according to Wilson's system (modified from Hardy) had no statistically significant correlation with DS degree of descent. Presence of residual tumor on postoperative magnetic resonance images was significantly correlated with Wilson's classification and with supradiaphragmatic tumor height. On the other hand, cerebrospinal fluid leak showed no statistically significant difference between variable degrees of DS descent. Volumetric data of the tumor portion above the diaphragma opening are more important than morphological data for prediction of surgical field block caused by descended DS. While DS prolapse significantly increases the difficulty of the operative procedure, residual tumor presence is mainly dependent on morphological classification, especially cavernous sinus invasion.

Utility of optical coherence tomography in the evaluation of sellar and parasellar mass lesions

PURPOSE OF REVIEW

Anterior visual pathway compression is a common feature of sellar region masses. We review the visual pathway neuroanatomy pertaining to sellar and parasellar lesions and describe recent advances in optical coherence tomography (OCT) imaging that have provided a novel quantitative perspective in the evaluation and management of such patients.

RECENT FINDINGS

Ultrastructural measurements of optic nerve integrity using OCT, namely peripapillary retinal nerve fiber layer (pRNFL) and the ganglion cell and inner plexiform layer (GCIPL) thicknesses, have been shown to correlate with visual acuity and visual field deficits on perimetry in patients with compressive sellar region masses. In some cases, OCT can visualize early signs of anterior visual pathway involvement in the absence of clinically evident visual field loss or optic disc pallor. OCT is particularly useful when assessing patients who demonstrate less reliable visual field testing. Furthermore, there is growing awareness that pRNFL and GCIPL thinning preoperatively correlate with worse visual recovery following chiasmal decompression, highlighting the prognostic utility of OCT in this patient population.

SUMMARY

OCT provides a complimentary, yet critical, role in quantitatively assessing ultrastructural retinal injury in patients with sellar and parasellar lesions compressing the anterior visual pathway and should be incorporated into routine evaluation.

Imaging Evaluation of the Location and Fenestration of Sellar Floor During Endonasal Transsphenoidal Surgery in Patients with Pituitary Adenomas

OBJECTIVE

To evaluate clinical value of three-dimensional (3D) computed tomography (CT) reconstruction of the sphenoid sinus separation in localizing sellar floor during endonasal transsphenoidal surgery and determine size and location of sellar floor fenestration.

METHODS

There were 51 patients eligible for study inclusion. Preoperative CT scan of the paranasal sinus and CT scan and magnetic resonance imaging of the pituitary gland were obtained. Sphenoid sinus separation was reconstructed using Mimics 15.0 software, and quantity, shape, and orientation were observed and compared with intraoperative data to guide the localization of sellar floor. Anatomic variation of the sphenoid sinus and adjacent structures, tumor and sella turcica morphology, minimal distance between the cavernous segment of the internal carotid artery bilaterally, and shortest distance from the midline were measured.

RESULTS

Based on the shape of the sphenoid sinus separation, sellar floor was accurately localized in all cases. Intraoperative sphenoid sinus separation was consistent with preoperative three-dimensional CT reconstruction images. The sellar floor was extremely small in 2 patients, and insufficient fenestration of sellar floor negatively affected tumor resection. Preoperative three-dimensional CT reconstruction is helpful for accurate and rapid localization of sellar floor.

CONCLUSIONS

Anatomic variation of sphenoid sinus and adjacent structures, characteristics of tumor and sella, minimum distance between bilateral cavernous segment of the internal carotid artery, and shortest distance from midline are helpful for establishment of individualized sellar floor fenestration.

Radiological presentation of chondromyxoid fibroma in the sellar region: A CARE-compliant article and literature review

RATIONALE

Chondromyxoid fibroma (CMF) is a rare benign bone neoplasm which often occurs in the lower extremities. Little is known about the radiological and histological presentation of CMF in the sellar region.

PATIENT CONCERNS

A 16-year-old Asian male presented to the hospital 12 months ago with bilateral diplopia involving right visual fields, intermittent headaches, and dizziness.

INTERVENTIONS

After the patient underwent enough examinations, the lesion was surgically removed by curettage.

DIAGNOSIS

Postoperatively, the lesion was pathologically confirmed to be CMF.

OUTCOMES

There was no recurrence at the 12-month follow-up.

LESSONS

To the best of our knowledge, this is the second reported case of CMF in the sellar region which was clinically suspected to be a pituitary macroadenoma, craniopharyngioma, or schwannoma due to its location and radiographic features. We reviewed the morbidity, symptoms, radiographic features, pathological findings, and differential diagnosis of CMF. Because of its rarity, attention should be paid to avoid misdiagnosis of this lesion.

DIAGNOSIS OF ENDOCRINE DISEASE: Primary empty sella: a comprehensive review

Primary empty sella (PES) is characterized by the herniation of the subarachnoid space within the sella, which is often associated with variable degrees of flattening of the pituitary gland in patients without previous pituitary pathologies. PES pathogenetic mechanisms are not well known but seem to be due to a sellar diaphragm incompetence, associated to the occurrence of upper sellar or pituitary factors, as intracranial hypertension and change of pituitary volume. As PES represents in a majority of cases, a neuroradiological findings without any clinical implication, the occurrence of endocrine, neurological and opthalmological symptoms, due to the above describes anatomical alteration, which delineates from the so called PES syndrome. Headache, irregular menses, overweight/obesity and visual disturbances compose the typical picture of PES syndrome and can be the manifestation of an intracranial hypertension, often associated with PES. Although hyperprolactinemia and growth hormone deficit represent the most common endocrine abnormalities, PES syndrome is characterized by heterogeneity both in clinical manifestation and hormonal alterations and can sometime reach severe extremes, as occurrence of papilledema, cerebrospinal fluid rhinorrhea and worsening of visual acuity. Consequently, a multidisciplinary approach, with the integration of endocrine, neurologic and ophthalmologic expertise, is strongly advocated and recommended for a properly diagnosis, management, treatment and follow-up of PES syndrome and all of the related abnormalities.

Bilateral Tolosa-Hunt syndrome mimicking pituitary adenoma

The authors report a rare case of bilateral Tolosa-Hunt syndrome, which occurred in a 80-year-old female and remitted spontaneously. Inflammatory lesions were found not only in typical locations, i.e. superior orbital fissures and cavernous sinuses, but also in the pituitary; these imitated gland's macroadenoma in imaging studies.

Moyamoya Disease Associated with Tuberculum Sellae Meningioma and Cavernous Sinus Hemangioma

BACKGROUND

Primary moyamoya disease associated with skull base tumors has been reported only rarely in the literature. Surgical treatment can be complicated due to the compensatory collateral circulation through meningeal and leptomeningeal anastomosis. A standard frontotemporal craniotomy may interrupt critical transdural anastomoses.

CASE DESCRIPTION

We report a case of primary moyamoya disease coexisting with tuberculum sellae meningioma and left cavernous sinus hemangioma. Simultaneous management of tuberculum sellae meningioma and moyamoya disease was performed using a left modified pterional incision. Two separate bone windows were opened to protect the transdural anastomosis via the middle meningeal artery. The tuberculum sellae meningioma was successfully removed through a small frontal craniotomy, and encephaloduromyosynangiosis was used to treat moyamoya disease through a temporoparietal craniotomy. Finally, CyberKnife radiotherapy was used to treat the left cavernous sinus hemangioma at 6 weeks after the initial operation. The patient recovered well without complications. This is the first report of moyamoya disease associated with tuberculum sellae meningioma and cavernous sinus hemangioma.

CONCLUSIONS

With careful bone flap design, moyamoya disease and skull base tumors can be treated simultaneously. Care should be taken to avoid interruption of critical dural-pial collaterals and injury to fragile moyamoya vessels.