Dynamic Roentgenographic Changes in the Empty

Sella Syndrome
1
Charles B. Grossman, M.D.
Two cases of empty sella syndrome are presented. Progressive sellar enlargement was
documented together with evidence of increased intracranial pressure. One patient ex-
hibited de novo development of an empty sella turcica.
INDEX TERMS: Cisterns, subarachnoid. Sella Turcica. Skull, pressure in
RadIology 116:341-344, August 1975
Neuroradiology
B
USCH (3) USED the term " empty sella" to describe
the anatomical appearance of pituitary remodeling
associated with extension of the subarachnoid space
into the sella turcica. Robertson (15) described air ex-
tending into the sella during pneumoencephalography.
Many recent reports concerning enlargement of the
sella turcica associated with an intrasellar cistern have
been published (7, 9, 10, 17). The triad of sellar remod-
eling in association with pneumoencephalographic evi-
dence of an intrasellar cistern and pituitary remodeling
represents the radiological correlates of the anatomical
term " empty sella" as defined by Busch (3, 9). Enlarge-
ment of the sella is not necessary for the radiological di-
agnosis (10). Hodgson et al. (8) used the terms " idio-
pathic" to describe spontaneous occurrence and "sec-
ondary" to describe the postsurgical or postirradiation
empty sella. Very few longitudinal studies of sellar re-
modeling have been reported. Further enlargement of
an already enlarged sella turcica has been documented
in one case of pseudotumor cerebri (16) and suggested
in 2 cases of idiopathic empty sella syndrome (8) . The
frequent association of the empty sella syndrome and
cerebrospinal fluid rhinorrhea has been reported (2, 14).
Two cases in which dynamic radiological changes were
seen in association with the empty sella syndrome are
described below.
CASE REPORTS
CASE I: A 35-year-old woman was hospitalized for evaluation of
mild systemic hypertension and headaches. Five years earlier she
had had a transient episode of occipital and vertex headaches. Skull
films were normal. Mild systemic hypertension had been noted two
years before admission. The patient had had episodic occipital and
vertex headaches for one year as well as occasional ringing in the
r ight ear and was being treated with small doses of Valium. She was
not using oral contraceptives and had given birth to a normal child
ten years earlier. Her only other pregnancy terminated in a first-tri-
mester spontaneous abortion eight years before admission. She had
no major illnesses, symptomatic crises, or menstrual abnormalities.
On clinical examination, the patient was mildly obese and her
blood pressure was 130/88. The remainder of the physical examina-
tion was normal, including visual fields and thorough examination of
the nervous system, ears , nose, and throat . Cerebrospinal fluid pres-
sure and analysis, routine laboratory tests, serum chemistries and
electrolytes, and extensive endocrine tests were normal, as were
the chest films. excretory urogram, electroencephalogram, and
brain scan. Comparison of the skull films with those taken five years
earlier showed that the mean volume of the sella turcica, which had
previously been normal according to the criteria of Oi Chiro et al. (5)
(Fig. 1), was now almost four times as large (Fig. 2). The diameter of
Fig. 1. A and B. CASEI. Anteroposterior (A) and lateral (B) skull projections taken in 1968. The sella turcica appears normal and its vol-
ume is 637 mm
3
. The arrow indicates the floor of the sella turcica.
Fig. 2. A and B. CASEI. Anteroposterior (A) and lateral (B) skull projections takenin 1973. The volume of the sella turcica has expand-
ed to 2,430 mm", The lamina dura and dorsum sellae are intact. The arrow indicates the floor of the sella turcica.
1 From the Departments of Radiology of Episcopal Hospital and Temple University Health Sciences Center, Philadelphia , Pa. Revised version
accepted for publication in April 1975. sjh
341
342 CHARLES B. GROSSMAN August 1975
Fig. 3. A and B. CASE I. Half-axial skull projections taken in 1968 (A) and 1973 (B). The diameter of the occipital emissary venous ca-
nals (arrows) has doubled.
Fig. 4. A and B. CASEI. Lateral skull projections taken in 1968 (A) and 1973 (B) show a marked increase in the diameter of the frontal
diploic venous canals (arrows).
Fig. 5. A and B. CASE I. Standard basal skull projection (A) and tomogram (B), both taken in 1973. The left foramina
ovale and spinosum are enlarged, with smooth, clearly defined margins (large arrows). Note the remnant of the septum separat-
ing the foramina (small arrow). The normal right foramina ovale and spinosum are seen on both basal projections.
the occipital emissary venous foramina had doubled (Fig. 3) and the
diameter of the frontal diploic venous canals was markedly in-
creased (Fig. 4). Erosion of the left foramina ovale and spinosum
with clearly defined margins was noted on the basal projection (Fig.
5), not obtained in 1968.
Selective catheter arteriography of the left internal and exter-
nal carotid, right common carotid, and left vertebral arteries failed to
demonstrate evidence of an aneurysm, mass, abnormal arteries, or
abnormal blush. Two left middle meningeal arteries originating from
the left maxillary artery appeared to traverse the anterior and poste-
rior limits of the eroded foramina at the left base. Neither artery was
enlarged, stretched, or displaced. A prominent left pterygoid venous
plexus was seen on the left carotid (Fig. 6). The dural
venous sinuses were patent. The ophthalmic, occipital emissary,
and frontal diploic veins were opacified, and the diploic veins were
enlarged as well (Fig. 6). Pneumoencephalography demonstrated an
air-filled intrasellar cistern, a remodeled pituitary gland, a posteriorly
positioned optic chiasm, and normal ventricular anatomy (Fig. 7).
There was no evidence of a temporal or subtemporal mass. The pa-
tient was discharged without additional medications or therapy and
has remained asymptomatic. Repeat examination 15 months later
revealed no abnormalities. Skull films were unchanged, and a com-
puted axial tomogram of the brain was normal.
CASEII: A 35-year-old multiparous obese woman was evaluated
for systemic hypertension. A hysterectomy had been performed
three years earlier for irregular menstrual bleeding. Due to question-
able papilledema, a lumbar puncture was performed and a skull se-
ries was obtained. The cerebrospinal fluid opening pressure was 195
mm Hg. Endocrinologic tests were normal. The skull series demon-
strated an enlarged sella turcica with a demineralized lamina dura
(Fig. 8). Pneumoencephalography documented an empty sella turci-
ca (Fig. 9). Bilateral carotid angiograms were normal.
Four years later the patient was evaluated for cerebrospinal fluid
rhinorrhea which developed following the abrupt remission of a
three-week episode of severe headaches. A skull series demon-
strated a twofold increase in the volume of the sella as well as ero-
sion of the lamina dura (Fig. 10). Pneumoencephalography recon-
firmed the empty sella turcica (Fig. 11) and 111In_DTPA cisternogra-
phy documented CSF rhinorrhea (Fig. 12). The cerebrospinal fluid
Vol. 116 DYNAMIC ROENTGENOGRAPHIC CHANGES IN THE EMPTY SELLA SYNDROME 343 Neuroradiology
Fig. 6. A and B. CASE I. Left internal carotid arteriogram, late venous phase : anteroposterior (A) and lateral tB) pro-
jections. 1 = opacified ophthalmic veins; 2 = frontal diploic veins; 3 = occipital emissary vein; 4 = prominent left ptery-
goid venous plexus.
Fig. 7. A and B. CASE I. Brow-up anteroposterior (A) and lat-
eral (B) tomograms taken during pneumoencephalography. Air in the
intra sellar cistern outlines the surface of the remodeled pituitary
gland (large arrows). The posterior position of the optic chiasm
(small arrow) suggests that the diaphragma sellae is widened.
pressure and endocrinologic findings were normal, At surgery, the
large intrasellar cistern was confirmed. The sella was packed with
muscle. and the patient had an uneventful recovery.
DISCUSSION
Cerebrospinal fluid pulsation through an incomplete
diaphragma sellae is generally accepted as the mecha-
nism by which an empty sella develops (10), and elevat-
ed intracranial pressure has also been considered as an
etiologic factor (6, 7, 10, 11). Characteristically, the id-
iopathic type of empty sella syndrome occurs in middle-
aged obese women complaining of headaches or sinus-
itis who have normal endocrine function (8) or mild
hypopituitarism (1). Cerebrospinal fluid rhinorrhea fre-
quently occurs in the empty sella syndrome (2, 14),
enhancing speculation as to the etiologic role of raised
intracranial pressure in this condition (7, 10).
The first patient had clinical, laboratory, and radiologi-
cal findings typical of the empty sella syndrome. In addi-
Fig. 8. A and B. CASE II. First admission, lateral (A) and basal
(B) skull projections. The lamina dura is demineralized (large arrow)
and the sella turcica is greatly expanded, now measuring 3,230 mm
3
in volume. The small arrows indicate the anterior limit of the sella
turcica.
tlon, there was evidence of increased intracranial pres-
sure. The posterior position of the optic chiasm and the
free access of cflr to the intrasellar cistern suggested a
deficient diaphragma sellae (17), while the enlargement
of the occipital emissary vein was evidence of in-
creased intracranial pressure (4). EI Gammal and Allen
noted that 2 of their 24 patients with an empty sella had
prominent pterygoid veins and reported the same finding
in other unrelated cases (7). The direction of venous
flow through the ophthalmic, frontal diploic, pterygoid,
and occipital emissary veins formed an unusual pattern.
It is known that the rete of the foramen ovale connects
the cavernous sinus with the pterygoid venous plexus
(12); thus it would seem likely that erosion of the left fo-
ramina ovale and spinosum is secondary to an increase
in the caliber of the traversing veins, as is enlargement
of the occipital emissary and frontal diploic veins.
The second patient also had clinical and roentgeno-
graphic findings typical of the empty sella syndrome.
The marginally elevated intracranial pressure during the
344 CHARLES B. GROSSMAN August 1975
Fig. 9. CASE II. First admission: pneumoencephalo-
gram, brow-up lateral projection with the head hanging dem-
onstrates an air-fluid level (arrows) in the intra sellar cistern.
The optic chiasm is in a posterior position (single arrow).
Fig. 11. A and B. CASEII. Second admission: brow-up frontal
(A) and lateral tomograms {B) taken during pneumoencephalogra-
phy. Air fills the intrasellar cistern (arrows). The optic chiasm is opa-
cified (B, black arrow).
first admission and the lamina dura erosion that oc-
curred during the interval between admissions suggest
that the intracranial pressure probably increased at this
time, and the twofold increase in sellar volume and the
development of cerebrospinal fluid rhinorrhea may have
been secondary to this rise in intracranial pressure.
ACKNOWLEDGMENTS: I wish to thank Dr. Herbert Goldberg of the
Philadelphia General Hospital for the roentgenograms representing
the first admission of the patient in CASE II and Dr. D. Gordon Potts of
The New York Hospital for his help in reviewing this manuscript.
Department of Radiology
Episcopal Hospital
Philadelphia, Pa. 19125
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Fig. 10. A and B. CASE II. Second admission: lateral (A) and
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Fig. 12. CASEII. Second admission: four-hour
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