Ectopic Pituitary Neuroendocrine Tumors/Adenomas Around the Sella Turcica

Functional or non-secretory ectopic pituitary neuroendocrine tumors (PitNET) can form around the sella turcica during the development of the adenohypophysis by differentiating and detaching from the pharyngeal roof. These tumors usually appear in the sphenoid sinus, clivus, cavernous sinus, infundibulum, and suprasellar cistern. Ectopic PitNETs typically display the characteristic magnetic resonance imaging findings of pituitary adenomas. However, preoperative diagnosis of PitNETs is usually challenging because of the variety of clinical and imaging presentations, locations, and sizes. Ectopic suprasellar PitNETs resemble mass lesions in the pituitary stalk. Ectopic cavernous sinus of PitNETs are typically microadenomas in the medial wall. Ectopic sphenoclival tumors are characterized by more aggressive tumor activity than the other ectopic PitNETs. Although ectopic PitNETs are exceedingly rare, they should be considered as a differential diagnosis for masses around the sella turcica. Treatment of the disease should be individualized and may include medical care, surgical resection, gamma-knife radiosurgery, and radiotherapy.

Assessing the relationship between single nucleotide polymorphisms in Wingless signaling pathway genes and sella turcica morphology

Sella turcica development involves molecular factors and genes responsible for ossification. It is possible that single nucleotide polymorphisms (SNPs) in key genes are involved in morphological variation of sella turcica. Genes belonging to the WNT signaling pathway are involved in the ossification process and are candidates of sella turcica morphology. This study aimed to evaluate if SNPs in WNT6 (rs6754599) and WNT10A (rs10177996 and rs3806557) genes are associated with the calcification and patterns of the sella turcica. Nonsyndromic individuals were included in the research. Cephalometric radiographs were examined and the sella calcification was evaluated and classified according to the calcification of the interclinoid ligament (no calcification, partial calcification, and incomplete calcification) and sella turcica pattern (normal sella turcica, bridge type A-ribbon-like fusion, bridge type B-extension of the clinoid processes, incomplete bridge, hypertrophic posterior clinoid process, hypotrophic posterior clinoid process, irregularity in the posterior part, pyramidal shape of the dorsum, double contour of the floor, oblique anterior wall, and oblique contour of the floor). DNA samples were used to evaluate SNPs in the WNT genes (rs6754599, rs10177996, and rs3806557) using real-time PCR. Chi-square test or Fisher's exact test were used to compare the allele and genotype distributions according to sella turcica phenotypes. The alpha was set as 5% for all comparisons. A total of 169 individuals were included, 133 (78.7%) present sella turcica partially or completely calcified. Sella turcica anomalies were found in 131 individuals (77.5%). Sella turcica bridge type A (27.8%), posterior hypertrophic clinoid process (17.1%), and sella turcica bridge type B (11.2%) were the most prevalent morphological patterns observed. Individuals carrying the TT genotype in rs10177996 (TT vs. CT + CC) had higher chance to present a partially calcified sella turcica (p = 0.047; Odds ratio = 2.27, Confidence Interval 95% 1.01-5.13). In conclusion, the SNP in WNT10A is associated with the calcification phenotype of the sella turcica, the pleiotropic effect of this gene should be taken into consideration in future studies.

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.

Postnatal sellar spine growth: A case report and literature review

BACKGROUND

A sellar spine is a bony spur protruding anteriorly from the central portion of the dorsum sellae. Its etiology is an ossified notochordal remnant of the cephalic end of the notochord. It is presumed to be a congenital malformation based on magnetic resonance imaging (MRI) findings of sellar spine in a 4-year-old boy. A sellar spine should therefore be detectable at birth with or without ossification, and the posterior pituitary lobe should be displaced.

METHODS AND RESULTS

Here we review the literature and report the first case of typical sellar spine in an 8-year-old girl who presented with precocious puberty, but her MRI taken at age 4 months for a febrile convulsion did not show a sellar spine or posterior pituitary lobe deformation. T1-weighted sagittal images at 8 years old showed a bony structure protruding anteriorly from the central portion of the dorsum sellae. The length of this lesion was 3.8 mm on computed tomography (CT) scanning at 9 years old, and it elongated to 4.7 mm on CT at 12 years old.

CONCLUSIONS

Based on the present case, we speculate that the sellar spine would be too small to detect early in development and would grow in size after birth. In this case, a sellar spine and precocious puberty were potentially associated due to deformation of the growing pituitary gland.

Imaging of the pituitary and sella turcica

The pituitary gland is housed in the sella turcica and has vital endocrinologic functions. It lies in close proximity to numerous vital structures, including the optic chiasm, sphenoid sinus, cavernous sinus and hypothalamus. An understanding of the function, anatomy and embryology of the pituitary gland and its surrounding structures is vital to understanding its normal appearance, as well as in evaluating the broad spectrum of pathology that can involve the pituitary gland. Imaging of pathology in the sellar region, including pituitary adenomas, meningiomas, craniopharyngiomas and aneurysms, plays an important role in guiding treatment decisions. Modern imaging techniques are also important in evaluating the pituitary gland after surgery.

Incidence of bridging and dimensions of sella turcica in Class I and III Turkish adult female patients

Mineralization of the interclinoid ligament of the sella turcica, or sella turcica bridging, has been associated with severe craniofacial deviations. The aim of this study was to evaluate the incidence of sella turcica bridging, sella turcica dimensions, and skeletal variables in 57 Class I (mean age, 27.2 ± 5.3 years) and 61 Class III (mean age, 25.8 ± 4.6 years) Turkish adult females. Sella bridging was found in three (5%) of the Class I and 11 (18%) of the Class III individuals (P<.010). The association between sella turcica bridging and manifest skeletal Class III malocclusions was statistically significant according to the chi-square test (P<.050). No significant differences in sella turcica dimensions were found between the Class I and Class III patients. Skeletal variables that differed significantly were SNB (P=.004), ANB (P=.002), and NAPg (P=.000) angles and N-B (P=.030), N-Pg (P=.003), Go-Pg (P=.007), and TM-Pg (P=.002) dimensions.

Morphology of the sella turcica in Axenfeld-Rieger syndrome with PITX2 mutation

BACKGROUND

Axenfeld-Rieger syndrome (ARS) is a rare autosomal dominant disorder with an incidence of 1:200 000. Genotype and phenotype are heterogeneous and clinical morphology impresses with variable expressivity. Additionally to the typical craniofacial and dental aberrations anomalies in the morphology of sella turcica are discussed.

METHOD

In a multidisciplinary genetic and clinical study four patients of a family with ARS were screened by direct DNA sequencing. Radiographic analysis of the patients was performed for evaluating cranial and dental structures. Additionally, a specific analysis of the morphology of the sella turcica was made on the radiographs.

RESULTS

Screening for PITX2 and FOXC1 mutations revealed a P64L missense mutation in PITX2 in all four patients. The cephalometric analysis showed a midface hypoplasia associated with a skeletal Class III. All patients showed a sella turcica bridge combined with a prominent posterior clinoid process followed by a steep clivus and an elongated sella turcica.

CONCLUSION

The incidence of a sella turcica bridge in combination with a PITX2 mutation would suspect that sella turcica anomalies are typical symptoms of the syndrome. Sella turcica anomalies in association with craniofacial and dental aberrations, such as maxillary retrognathia, skeletal Class III relationship and hypoplasia of teeth, might be important indicators for ARS caused by PITX2 mutation.

Transsellar transsphenoidal rhino-oral encephalocele

Transsphenoidal encephaloceles are rare and the transsellar variety is the least common. We present a 1-year-old male patient with transsellar transsphenoidal encephalocele which herniated into the oral cavity through the congenital split palate. The patient was operated on using a combined transcranial and transpalatal approach without mortality or permanent morbidity. Clinical findings, imaging reviews, surgical repair techniques and postoperative morbidity are discussed with the relevant literature. We conclude that repair of a transsphenoidal encephalocele should be coordinated between a team of neurosurgeons and otorhinolaryngologists. Our surgical outcome supports a transcranial approach for the treatment of these difficult lesions, with transpalatal dissection and exposure.

A novel missense mutation (P366T) of the LHX4 gene causes severe combined pituitary hormone deficiency with pituitary hypoplasia, ectopic posterior lobe and a poorly developed sella turcica

LIM homeodomain transcription factors regulate many aspects of development in multicellular organisms. LHX4/Lhx4 is a protein that is essential for pituitary development and motor neuron specification in mammals. In human, a heterozygous splicing mutation of the LHX4 gene was reported in a family with combined pituitary hormone deficiencies (CPHD). In addition to CPHD, these patients were characterized by small sella turcica and chiari malformation. Here we report a Japanese patient with CPHD (GH, PRL, TSH, LH, FSH, and ACTH deficiency) due to a novel missense mutation (P366T) of the LHX 4 gene. She showed severe respiratory disease and hypoglycemia soon after birth. Brain MRI demonstrated hypoplastic anterior pituitary, ectopic posterior lobe, a poorly developed sella turcica, and chiari malformation. Sequence analysis of the LHX 4 gene identified a heterozygous missense mutation (P366T) in exon 6, which was present in LIM4 specific domain. Neither of the patient's parents harbored this mutation, indicating de novo mutation.

GH deficiency with central precocious puberty: a new rare disorder associated with a developmental defect of the hypothalamic-pituitary area

CONTEXT

GH deficiency (GHD) associated with central precocious puberty (CPP) has been widely reported in cases of arachnoid cyst, septo-optic dysplasia, brain tumors, or after cerebral radiation therapy. However, idiopathic GHD associated with CPP has been reported in only one isolated case.

OBJECTIVE

To evaluate the occurrence and clinical features of the association of nonacquired GHD and CPP.

DESIGN AND SETTING

This was a retrospective multicenter study.

PATIENTS AND METHODS

The study population was identified through a French nationwide multicenter network (about 3000 patients). We reviewed the medical records of all subjects diagnosed with nonacquired GHD and CPP, with or without developmental abnormalities of the hypothalamic-pituitary axis on cerebral magnetic resonance imaging (MRI), and without any known associated anomaly.

RESULTS

We identified four patients with either isolated GHD (n=1) or multiple anterior pituitary hormone deficiencies (n=3). Clinical signs of CPP occurred at 6.4 +/- 2.3 years in boys and 7.5 +/- 0.5 years in girls, and GnRH analog therapy was started at 4.2 +/- 1.6 years after the initiation of recombinant human GH treatment. Cerebral MRI demonstrated ectopic neurohypophysis associated with anterior pituitary hypoplasia in three out of the four patients. The morphology and position of the anterior pituitary and neurohypophysis were normal in one patient who displayed a persistence of the craniopharyngeal canal.

CONCLUSIONS

CPP is very rare in patients with nonacquired GHD and is mostly associated with developmental defects in the hypothalamic-pituitary area. Whether molecular mechanisms governing development and activation of the hypothalamic-pituitary axis share dependent factors remains to be explored.

A boy with small supernumerary marker chromosome X identified by FISH

Marker or ring X chromosomes are frequently seen in Ullrich-Turner Syndrome with 46,X,r(X) karyotype, but only 8 children were reported with an extra marker X chromosome in at least some of their cell lines, we describe a 5 years old male patient who is mosaic (17%) for a cell line with an extra ring shaped marker X chromosome in addition to a normal 46,XY cell line. He had mild motor mental retardation, a dysmorphic face, dysplastic ears, high arched palate, cryptorchidism and brachydactyly. G-banding showed 46,XY[83]/47,XY,+r?[17] karyotype. NOR banding revealed no satellite region but its centromere was intact in C-banding. By fluorescent in situ hybridization (FISH) technique, dual X/Y alpha-satellite probes were used to detect the origin of ring shaped marker chromosome and 17% of his cells had two X chromosome signals due to marker X; hybridization with X chromosome inactivation center (XIST) specific probe revealed the absence of the locus on the ring chromosome. In this report, clinical features of our patient are compared with previously reported cases and the cytogenetic and molecular cytogenetic techniques used to detect origin of marker chromosome are discussed.

The incidence and types of sella and sphenopetrous bridges

The incidence and types of sella and sphenopetrous bridges were investigated in 37 adult male and 43 adult female (a total of 80) dry skulls with removed calvarias. In addition to this, the sellar and parasellar region of ten fixed cadavers (two female and eight male) were carefully dissected, and the individuals were examined for the evidence of sella and sphenopetrous bridges. Sella bridges were seen in 34.17% of the subjects overall. The trace, incomplete and complete types were 11.9%, 3.7% and 17.5%, respectively. On the other hand, sphenopetrous bridges were observed in 15.8% of the male and 4.9% of the female subjects overall. The cadaveric investigation revealed one trace, three incomplete, and one complete sella bridge in three cadavers. In addition to this, a complete sphenopetrous bridge was detected in one of the cadavers. Variations in the cranial base are of importance for surgical approaches in that location.

Hypothalamic hamartoma associated with a craniopharyngeal canal

Hypothalamic hamartoma is a rare congenital lesion. We present the case of a 7-year-old girl who suffered from precocious puberty, the cause of which was diagnosed by using MR imaging and CT as pedunculated hypothalamic hamartoma associated with a large craniopharyngeal canal and sellar spine mimicking pituitary duplication.

Pituitary apoplexy due to prolactinoma in a Taiwanese boy: patient report and review of the literature

We report a Taiwanese boy who presented with apoplexy of a prolactinoma. A 12 9/12 year-old boy presented to our clinic with headache and visual deficit of bitemporal hemianopsia. Skull X-ray showed an enlarged sella. Magnetic resonance imaging (MRI) of the sella turcica showed a 4 x 2.5 x 2.5 cm mass, located at the sella turcica and extending upward to compress the optic chiasm. Preoperative laboratory data showed hyperprolactinemia, hypothyroidism and hypocortisonism. After a stress dose of i.v. hydrocortisone was given, he underwent transsphenoid surgery to remove the tumor. Immunohistochemical stains were positive for PRL in the tumor cells. After surgery, he suffered from neurogenic diabetes insipidus, hypopituitarism and hyperprolactinemia, with serum PRL level of 491 ng/ml. Visual field examination was normal 4 months later. In conclusion, pituitary apoplexy is rare in children but should be considered if a patient suffers from headache, vomiting, and visual deficit. Brain MRI is preferred for diagnosis. Dopaminergic agonists should be given if residual tumor or recurrence of prolactinoma is found after transsphenoidal surgery.

Agenesis of the internal carotid artery and congenital pituitary hypoplasia: proposal of a cause of congenital hypopituitarism

We describe a patient with microphallus without pigmentation and multiple pituitary hormone deficiencies. The left internal carotid artery and carotid canal were absent and the pituitary gland and sella turcica showed hypoplasia on MRI and magnetic resonance angiography. The internal carotid artery develops in the 4th embryonic week, while the pituitary primordium develops in the 3rd to 4th week. This suggests a possible relationship between internal carotid artery and congenital hypopituitarism. However, there is bilateral blood supply to the hypophysis via the superior and inferior hypophysial arteries, so it is unknown why pituitary hypoplasia may arise from blocking the unilateral blood supply.

CONCLUSION

Disruption of internal carotid artery perfusion may lead to pituitary hypoplasia with congenital hypopituitarism as a new disease entity in humans.

Cephalometric assessment of cranial abnormalities in patients with acromegaly

OBJECTIVE AND PATIENTS

Patients with acromegaly (12 women, 26 men) and a control group (36 women, 50 men) were chosen for cephalometry to assess the size, shape and positional characteristics of the craniofacial bones and the upper airways.

RESULTS

When compared with the controls, patients of both sexes with acromegaly were found to have significant anomalies in the orofacial skeleton: increased facial height, elongated ascending ramus mandibulae and greater basion-supramentale distance, a negative difference between maxillary and mandibular protrusions, enlarged lower part of the gonion angle and of the angle of inclination of the maxilla, as well as alterations in the neurocranium: enlargement of sella turcica and of sinus frontalis and protrusion of the supraorbital ridges. As for the soft tissues, patients with acromegaly exhibited an elongated soft palate and a diminished angle between the uvular axis and the palatal plane. A comparison between the cephalometric parameters of patients with active acromegaly and those without active disease revealed no significant differences in either sex.

CONCLUSION

Patients with acromegaly exhibited an enlargement of all parts of the neurocranium and orofacial bones except the maxilla. The greatest anomaly was seen in the mandible, with greater enlargement of the ascending ramus than of the body of the mandible. The shape of this bone was also altered.

Neuroendocrinological aspects of primary empty sella

Neuroendocrinological aspects of 42 patients (33 women, 9 men) with primary empty sella confirmed by CT, cysternography and/or MR imaging were analyzed. The prominent symptoms were headache, visual disturbances and hypertension, occurring primarily in obese women (84.5%). Patients underwent dynamic endocrine testing consisting of insulin-induced hypoglycemia and anterior pituitary stimulation tests GnRH and TRH. Variable degree of pituitary dysfunction was observed in 28 (66.6%) patients. In this study 20 (47.6%) patients were presented with latent hypopituitarism, while manifest hypopituitarism, requiring replacement therapy, occurred in 8 (19%) patients. Mild hyperprolactinaemia was found in 3 patients. Even 14 (33.3%) patients had no evidence of endocrine dysfunction. Often mentioned diabetes insipidus and rhinoliquorrhea were not reported in this study.

Midline skeletodental morphology in holoprosencephaly

OBJECTIVE

The purpose of the present study was to analyze histologically the midline structures in a human fetus with holoprosencephaly and a single median maxillary central incisor.

METHODS

A human male fetus, CRL 137 mm, postconceptional age 18 weeks, with a diagnosis of holoprosencephaly, the cebocephalic type (one nostril), and alobar brain development, was investigated. After radiography, the cranial midline structures were examined histologically.

RESULTS

The histological examination revealed partial absence of the intermaxillary suture (in the region anterior to the central incisor), absence of the internasal suture, and partial absence of the metopic suture (caudal part). A single midline nasal bone was observed instead of two bilateral nasal bones, and a midline maxillary central incisor was found instead of two bilateral incisors. A short nasal septum, absence of crista galli, and partial absence of cartilaginous tissue anterior to the sella turcica in the region of the presphenoid bone were recorded.

CONCLUSIONS

The study shows that in the affected fetus, there were malformations of midline structures anterior to the sella turcica comprising suture development and cartilage development.

Craniofacial morphology, dentition, and skeletal maturity in four siblings with Seckel syndrome

OBJECTIVE

To describe the craniofacial morphology, dentition, and hand maturity in four siblings with Seckel syndrome.

PATIENTS

Two boys and two girls, with Seckel syndrome. The children studied showed extreme growth retardation, severe microcephaly, bird-headed profile with receding chin, prominent nose, mental retardation, and extremely delayed skeletal maturation. The growth hormone axis and pituitary thyroid function was normal.

METHODS

Skeletal and dental development were investigated from radiographic material, and a cephalometric analysis was performed from profile radiographs.

RESULTS

The craniums were remarkably small with an extremely short anterior cranial base (-4.3 to -5.5 standard units) and maxillary length (-3.8 to -4.7 SU). Differences in the morphology of the sella turcica were observed in girls and boys. Tooth maturity progressed normally. Tooth agenesis and tooth malformations were observed. Taurodontic root morphology was observed only in the girls. The approximate skeletal maturity showed retardation from 4 years 3 months to 4 years 11 months. Malformations of the hand-wrist skeleton occurred in the epiphyseal ossification centers of the middle phalangeal bone in the second, third, and fourth finger and in the distal phalangeal bone in the fifth finger. The epiphyseal ossification centers were lacking in the middle and distal phalangeal bones of the fifth finger.

CONCLUSION

The underlying gene defect in the affected children seemingly affects bone development and growth but not dental maturation and eruption.

A newly recognized syndrome of skeletal dysplasia with opalescent and rootless teeth

A Thai girl with skeletal dysplasia and dental anomalies was seen. Her anomalies consisted of disproportionately short stature, short neck, broad and depressed nasal bridge, broad chest in the anteroposterior dimension, kyphosis, widely spaced nipples, and protruded abdomen. Radiographic testing indicated that she had a large sella turcica, platyspondyly, hypoplastic acetabulum, and a small body of mandible. Both her deciduous and permanent teeth were equally opalescent, and most were rootless, with root development of the mandibular teeth more severely affected. Some maxillary roots were extremely short and tapered. Hypodontia was also observed. These findings represent a unique and hitherto undescribed syndrome of skeletal dysplasia with concomitant dental anomalies.

Aspects of skeletal development in fragile X syndrome fetuses

The purpose of the present investigation was to describe the skeletal development in prenatal fragile X syndrome. We studied fetuses (4 males, 2 females), with gestational ages (GA) 12-14 weeks, from 5 unrelated, different, known carrier mothers. Because of trauma to the fetus during abortion, different parts of the 6 fetuses were available for investigation. The vertebral column and the facial skeleton of all the fetuses were examined, the feet and hands of 5 fetuses, and the cranial base of 3 fetuses. The tissue remnants were examined radiographically and histochemically, and the results compared with previously published normal findings. Radiographic findings included normal ossification sequence, except for 1 fetus where there was an abnormal sequence in the first finger; normal morphology of ossification centres; and nasal bones were absent in the 5 fetuses and present in 1 (14 weeks of gestation). The histological study suggests presence of an acid mucopolysaccharide malfunction in the supporting tissue, because the normal cartilage resorption and orthochromatic cartilage reactions do not appear during the initial enchondral ossification. In addition, the apoptosis of ectodermally derived cells (notochord and palatal epithelial layers) appears delayed or abnormal. The sella turcica was malformed in the 2 fetuses investigated for sella turcica morphology.

The prenatal pituitary gland--hidden and forgotten

The sella turcica and pituitary gland in a human fetus (18 weeks gestation) with unilateral oro-ocular cleft combined with unilateral cleft lip and palate are described histologically. In this fetus the sella turcica was not a normal sella but a caudally open funnel. The adenopituitary gland tissue was positioned ectopically within the funnel canal and in the pharyngeal submucosa.

Postnatal structure of the sella turcica in Down syndrome

The purpose of this study was to analyze the shape of the sella turcica in a group of patients with Down syndrome and compare the findings with those made earlier in human fetuses with Down syndrome. Profile radiographs from 78 patients (age 4 months to 50 3/12 years) were analyzed. A tracing was made of each sella turcica, and the shape was compared with that of a normal sella, including the normal growth pattern from childhood to adulthood. Sella turcica structure could be classified into three morphological types, defined as: type I, almost normal appearance; type II, deviations in the anterior wall; and type III, deviations in the floor of the sella turcica. Compared with previously registered prenatal structural deviations in the sella turcica, it can be concluded that the postnatal radiographic material reflects the prenatal findings, because type I, both prenatally and postnatally, is by far the most common, whereas the remaining types are uncommon, both prenatally and postnatally. The study confirms the relevance of prenatal investigations for postnatal diagnostics as previously documented in sella turcica analyses of prenatal and postnatal myelomeningocele cases.

Malformations of cranial base structures and pituitary gland in prenatal Meckel syndrome

The sella turcica region, including the clivus and the pituitary gland, was studied histologically in five human fetuses with Meckel syndrome (MS). All cases had malformed sella turcica and malformed clivus with irregularly shaped notochordal remnants. We consider that these three characteristics are constant phenotypic traits in MS. The adenohypophysis was present in three cases. In one of these, ectopia of the gland occurred with adenopituitary tissue overlying the dorsum sella, and in another remnants were found in the pharyngeal submucosa. In two fetuses the neurohypophysis was not found. The findings in the region were compared to normal findings and to findings in trisomy 18, where cranial base structures radiographically appeared similar to those in MS. We conclude that in MS specific characteristics are found in the cranial base region and that radiographic analysis needs to be supplemented by histological analysis when studying this specific region.

Nevoid basal cell carcinoma syndrome. Clinical findings in 37 Italian affected individuals

Nevoid basal cell carcinoma syndrome (NBCCS) is a hereditary condition transmitted as an autosomal dominant trait with complete penetrance and variable expressivity. The syndrome is characterised by numerous basal cell carcinomas (BCCs), odontogenic keratocysts of the jaws, palmar and/or plantar pits, skeletal abnormalities and intracranial calcifications. In this paper, the clinical features of 37 Italian patients are reviewed. Jaw cysts and calcification of falx cerebri were the most frequently observed anomalies, followed by BCCs and palmar/plantar pits. Similar to the case of African Americans, the relatively low frequency of BCCs in the Italian population is probably due to protective skin pigmentation. A future search based on mutation screening might establish a possible genotype phenotype correlation in Italian patients.

Prenatal traces of aberrant neurofacial growth

The interrelation between the development of the brain/peripheral nerves and that of the surrounding bone tissue is termed neuro-osteology. In orthodontic and pediatric practice the development of the hard tissues is evaluated radiographically, but the development of the neural tissue within the bone tissue is not evaluated. In this review the emphasis is placed on two neuro-osteologic interrelations that can be observed on profile radiographs and orthopantomograms, respectively. One is the connection between the pituitary gland of the central nervous system and the sella turcica (profile radiograph), and the other is the association between the peripheral nerves and the development of the dentition (orthopantomogram). Pituitary gland/sella turcica: The correlation between prenatal malformation in the pituitary gland/sella turcica and the postnatal morphology of the sella turcica in holoprosencephaly, spina bifida/myelomeningocele, and cri-du-chat syndrome is demonstrated. Peripheral nerves/dentition: The prenatal innervation of the dentition is presented. Agenesis and tooth malformation occur in constant patterns within the dental arch fields that share the same innervation. The findings demonstrate that in postnatal diagnosis of the cranium and the teeth, traces of prenatal aberrations can be found that are important for neurofacial growth.

The sella turcica in children with lumbosacral myelomeningocele

The purpose of the present study was to analyze the morphology of the sella turcica in children born with myelomeningocele. Profile radiographs from 16 children (nine females and seven males) born with myelomeningocele were analysed. The contour of the anterior wall of the sella turcica in myelomeningocele patients, instead of following the normal cranio-caudal direction, was always in an obliquely antero-posterior direction. The sella turcica thus appeared broad cranially with a diverging anterior wall, or with both diverging anterior and posterior walls. This appearance gave and impression of a wide sella turcica in myelomeningocele with less depth than normal. The investigation has drawn attention to the fact that congenital malformations in the axial skeleton, even though, as in the case of myelomeningocele, they are located far from the cranial base, may have manifested themselves in the cranial base as well. The pathogenetic relationship between these manifestations is to be found in the early embryonic structure, the notochord. With the concept of embryological developmental fields, defined as areas with a common developmental origin, such as the notochordal field involved in myelomeningocele, new ways seem to be emerging for an improvement of aetiologically based diagnosis and treatment.

Pituitary gland and sella turcica in human trisomy 18 fetuses

The purpose of this study was to elucidate the phenotypic conditions in the sella turcica/pituitary gland complex in human trisomy 18 fetuses. Fourteen human fetuses with gestational ages from 12 to 39 weeks were included in the study. Normal fetuses at corresponding ages were used as controls. Whole body and special radiographic examination was undertaken before the midsagittal cranial base block, including the pituitary gland, was excised and analyzed histologically and immunohistochemically (keratin wide spectrum [KWS], thyroid-stimulating hormone [TSH], and neurophysin [Nph]). In all trisomy 18 fetuses, TSH-positive adenopituitary tissue was present in the sella and in greater or lesser amounts pharyngeally. The neurohypophysis was Nph-positive and located normally in the sella turcica. The adenohypophyseal tissue reacted either KWS-faint or KWS-negative, whereas KWS-positive reaction occurs in normal fetuses. This circumstance might suggest an altered cytoskeletal structure of the surface ectoderm in the pituitary placode in trisomy 18. The sella turcica was malformed in all the fetuses. Very broad craniopharyngeal canals were observed in some of the fetuses. Because endocrine disorders occur in many congenital malformations, it is essential in future studies to chart the sella turcica/pituitary gland region systematically in different genotypes.

Unusual magnetic resonance imaging findings of the sellar region in subjects with hypopituitarism: report of 4 cases

Out of 323 consecutive growth hormone deficient patients who underwent magnetic resonance imaging (MRI), we describe the clinical and neuroradiological characteristics of four patients in whom MRI revealed unusual pictures of the sellar area. They were selected as unique in their morphological picture and representative of rare conditions. At presentation all subjects had short stature, growth hormone (GH) deficiency and complex phenotypical abnormalities. Patient 1. Female affected by vaginal atresia and sinus urogenitalis, polydactyly and syndactyly with Y-shaped metacarpals. MRI at age 11.2 years revealed normal pituitary, but hypothalamic mass occupying the suprasellar and interpeduncular cistern. The diagnosis of Hall-Pallister syndrome was made. Patients 2 and 3. Two sisters with a history of epilepsy both showing mild intellectual deficiency, midface hypoplasia and ectodermal dysplasia. MRI at age 8 and 12 years respectively displayed in both cases a round hypointensity protruding from the dorsum sellae into a normal pituitary. The diagnosis was sellar spine. Patient 4. Male with a history of postnatal hypoglycemia showing microphallus and clinical features of severe hypopituitarism. Hormonal evaluation at age 8 months confirmed multiple pituitary hormone deficiencies and MRI at age 6 years showed absent anterior lobe, rudimentary stalk and posterior lobe ectopia. The diagnosis was pituitary aplasia. The patients described show that MRI in pituitary dwarfs can reveal unusual intrasellar findings and allow the correct diagnosis of rare syndromes. Our patients also demonstrate the wide variability in the association of hypopituitarism with midline congenital abnormalities and the possible combination with complex syndromes.

Familial spinocerebellar ataxia and empty sella turcica

Pituitary anomaly associated with familial spinocerebellar ataxia (FSCA) is a rare occurrence. This is a report of a child with FSCA who had an empty sella turcica and growth hormone deficiency. Growth hormone therapy accelerated growth velocity and improved muscular strength. Endocrinopathy associated with FSCA is reviewed.

Idiopathic intracranial hypertension in female homozygous twins

The authors report on female homozygous twins with idiopathic intracranial hypertension. At the age of 12 years, both twins simultaneously developed visual disturbances with photophobia. At the age of 19 years, an ophthalmological examination disclosed papilloedema in both their eyes. At the age of 22 years, a lumbar puncture showed raised CSF pressure over (200 mm H2O) in both twins. Their neurological and radiological examinations were extremely similar; both of them had severely impaired visual acuity and impaired visual field, bilateral optic nerve atrophy, intracranial hypertension, an enlarged and partial empty sella turcica, digital markings of the calvalium, and an enlarged frontal subarachnoid space. This is the first case report describing idiopathic intracranial hypertension occurring in homozygous twins.

CT and MRI of sellar spine with upward extension of the pituitary gland: case report

This is a report of CT and MRI findings in a patient with a sellar spine which caused deformity of the pituitary gland. The sellar spine is an infrequent anatomical variant characterized by an osseous spine which arises in the midline from the anterior aspect of the dorsum sellae and extends into the pituitary fossa. The CT and MRI findings of sellar spine have been described in previous reports; however, only one investigator reported deformity of the pituitary gland as revealed by CT. This is the first report of the MRI finding of the sellar spine associated with a deformity and superior extension of the pituitary gland, mimicking pituitary hypertrophy.

Clinical and roentgenographic findings in a patient with primordial microcephalic dwarfism type Caroline Crachami

We describe a patient with primordial microcephalic dwarfism with severe intrauterine growth retardation and severe and progressive postnatal deficit in length, weight and head circumference. The patient was extroverted and sociable but mildly mentally retarded. He had marked delay of bone maturation and an enlargement of the sella turcica. This child and two previously reported patients [Boscherini et al., Eur J Pediatr 137:237-242, 1981] have many characteristics in common with Caroline Crachami, the famous "Sicilian dwarf". We think that these patients belong to a separate category of microcephalic primordial dwarfism.

Human fetal pituitary gland in holoprosencephaly and anencephaly

The normal prenatal development of the human pituitary gland and the gland-supporting sella turcica has recently been investigated. The sella turcica area constitutes a developmental boundary area in the cranial base. Posterior to the area the cranial base has developed close to the notochord, and anterior to the region the cranial base development is dependent chiefly on neural crest cell migrations. In the present study the sella turcica region was analyzed in two fetuses with holoprosencephaly (cyclopia and median cleft) and four fetuses with anencephaly combined with rachischisis in the neck region (GA 16-20 weeks). The sella turcica region was investigated radiologically and histologically. Adenohypohyseal gland tissue was localized by immunohistochemical hormonal marking. In both types of malformation an open craniopharyngeal canal was seen in the base of the sella turcica with adenohypophyseal glandular tissue located in the sella turcica, in the canal, and in the pharyngeal connective tissue at the external side of the cranial base. In conclusion, severe malformations of the pituitary gland occur in both holoprosencephaly, which is a polytopic field defect located anterior to the sella turcica, and in anencephaly associated with notochordal insufficiency posterior to the sella turcica. This might indicate that the sella turcica area, bounding different developmental fields, is involved in various craniofacial malformations. It is consequently recommended that examination of the pituitary gland should become a part of the routine autopsy of prenatal material when malformations in the face, brain, and cranial base occur.

Mulibrey nanism: three additional patients and a review of 39 patients

We report on 3 patients with Mulibrey nanism (MN), or Perheentupa syndrome: the first 2 sibs from Argentina and a new patient from Spain. All 3 patients had growth failure, short stature, abnormal pigmentary retinal changes, and a J-shaped sella turcica. These findings are considered major criteria of MN. Two had pericardial constriction, which is a frequent and life-threatening abnormality in this syndrome. MN is a rare autosomal recessive condition. Reviewing the 39 patients described so far, we have classified the anomalies into the very frequent (present in more than 66%), frequent (in at least 25%), and not frequent. Identifying the anomalies specific to MN should help its early diagnosis and treatment.

Intrasellar bony spine, a possible cause of hypopituitarism

A 39-year-old male patient with long-standing pituitary deficiency is reported. The onset of hypopituitarism was probably at about the age of 12 years, but diagnosis was not made until 6 years later. Since then he has received substitutive hormonal treatment and was referred with complaints suggestive of growth hormone deficiency. Retrospective study of a skull radiography performed at the age of 18 years revealed a calcified lesion in the sellar region. Additional radiological examinations showed the presence of a 9-mm intrasellar bony spine. Magnetic resonance examination showed a ventrally extending arrow-shaped bone deformation in continuity with the dorsum sellae, consisting of a hyperintense structure comparable with the intensity of the bone marrow of the dorsum and clivus. Computed tomography scanning confirmed in detail the morphology of the bony spine. This deformity probably represents the non-regressed cephalic segment of the notochord. Only in four reports has the existence of this congenital abnormality been described, but this is the first one in which hypopituitarism can be regarded as a complication of the intrasellar spine.

Comparative three-dimensional analysis of CT-scans of the calvaria and cranial base in Apert and Crouzon syndromes

The purpose of this study is to describe and analyze Apert and Crouzon skulls from three-dimensional (3-D) reconstructions of CT-scans. 12 Apert patients and 19 with Crouzon syndrome were included in the study. The age range was 0 to 23 years. All CT-scannings were carried out according to the same protocol with a slice thickness of 2 or 4 mm and 3-D reconstructions of the craniofacial region included midsagittal and horizontal cuts. A number of qualitative characteristics of the calvaria and cranial base were recorded and the cranial base angle was measured on the 3-D models. Our results showed that Apert and Crouzon syndromes are very different in cranial development and their dysmorphology is highly age dependent. We suggest that cartilage abnormalities, especially in the anterior cranial base, play a primary role in cranial development in the Apert syndrome from very early intrauterine life. Several cranial anomalies observed postnatally, however, are caused by the resultant dysmorphic and compensatory growth and are probably compounded by early cranial deformation. The primary abnormality in Crouzon syndrome appears to be premature fusion of sutures and synchondroses. Based on the findings at birth and early infancy it would seem that such fusions occur relatively late in fetal life. The adult cranial form in Crouzon's patients is explainable by resultant dysmorphic and compensatory growth changes. Very early release of the coronal suture areas with advancement of the frontal bone is advocated in both syndromes but for somewhat different reasons.(ABSTRACT TRUNCATED AT 250 WORDS)

Slit defect of the diaphragma sellae with valve effect: observation of a "slit valve"

Malformations of the diaphragma sellae may permit transdiaphragmatic cerebrospinal fluid pulsations that lead to expansion of the sella turcica. The purpose of this report is to describe an intrasellar arachnoid cyst observed during surgery being filled by the action of an apparent one-way valve.

[Persistent trigeminal artery associated with pituitary adenoma]

The authors report of a case with a pituitary macroadenoma which was associated with a persistent trigeminal artery. The tumour was removed by transsphenoidal microsurgical approach to the sella turcica. To recognise the developmental anomaly is very important to avoid complications during operation.

Basal cell carcinoma syndrome: report of 10 cases

Ten cases of basal cell carcinoma syndrome are presented. The jaw cysts were proved histopathologically to be odontogenic keratocysts. The multiple naevoid lesions on the skin were identified as basal cell carcinoma in two cases. Skeletal anomalies and intracranial calcification were present in all cases. A positive family history with others affected by the syndrome was traced in two cases.

[A case of transsphenoidal meningoencephalocele]

A 6-year-old boy was sent to us due to basal meningoencephalocele detected by MRI. He had had a past history of strabismus and morning glory syndrome since 6 months of age, as well as hypopituitary dwarfism since he was 3 years old. On admission, physical examination revealed hypertelorism and left coloboma. Laryngoscopic examination revealed a round mass covered by normal nasal mucose in the midline of the tegmen of the choana. X-ray tomogram and CT scan demonstrated an isodense mass protruding into the nasopharyngeal cavity through a bony defect of the sella turcica. Right carotid angiogram showed stenosis of the right internal carotid artery and abnormal fine vessels in the basal ganglia similar to basal Moyamoya network. There was an irregular filling of the right anterior cerebral artery. Left carotid angiogram showed an irregular filling of the left middle cerebral artery. MRI showed an anterior part of the third ventricle descending into, and the meningocele protruding into the nasopharyngeal cavity. It also showed a stalk extending from the hypothalamus into the meningocele, but the pituitary gland was not recognized. The meningocele was of the same signal intensity as CSF in both T1 and T2 weighted images. Growth hormone deficiency was confirmed by radioimmunoassay of the peripheral blood. An operation was scheduled transcranial to prevent snoring during sleep at age 9. The stalk was observed behind the chiasm during the operation, but a radical operation was not performed because of a possibility of postoperative hypothalamic-pituitary dysfunction. Transsphenoidal encephalocele is rare. So far as we could see, only 30 cases have been reported.(ABSTRACT TRUNCATED AT 250 WORDS)