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Dynamic Roentgenographic Changes in the Empty
Sella Syndrome1
Charles B. Grossman, M.D.
Two cases of empty sella syndrome are presented. Progressive sellar enlargement wasdocumented 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
Neuroradio logy
BUSCH (3) USED the term " empty sella" to descr ibe
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 pitui tary 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 descr ibe the postsurgical or postir radiation
empty sella. Very few longitudinal studies of sel lar 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 associat ion 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 hospi ta lized 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 occ ipital 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 ear lier . Her only other pregnancy terminated in a f irst-tri mester spontaneous abortion eight years before admission. She had
no major i llnesses, 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
electro ly tes, 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
ear lier 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 t imes as large (Fig. 2). The diameter of
Fig. 1. A and B. CASE I. Anteroposterior (A) and lateral (B) skull projections taken in 1968. The sella turcica appears normal and its volume is 637 mm 3
. The arrow indicates the floor of the sella turcica.Fig. 2. A and B. CASE I. 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 versionaccepted for publication in April 1975. sjh
341
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342 CHARLES B. GROSSMAN August1975
Fig. 3. A and B. CASE I. Half-axial skull project ions taken in 1968 (A) and 1973 (B). The diameter of the occipital emissary venous canals (arrows) has doubled.Fig. 4. A and B. CASE I. Lateral skull project ions taken in 1968 (A) and 1973 (B) show a marked increase in the d iameter of the f rontal
diploic venous canals (arrows).
Fig. 5. A and B. CASE I. Standard basal skull projection (A) and tomogram (B), both taken in 1973. The lef t foraminaovale 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
c reased (Fig. 4). Erosion of the left foramina ovale and spinosum
with clearly defined margins was noted on the basal project ion (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 maxil lary artery appeared to traverse the anter ior and poste
r ior limits of the eroded foramina at the lef t base. Nei ther artery was
enlarged, stretched, or displaced. A prominent left pterygoid venous
plexus was seen on the left carotid a r t e ~ i o g r a m s (Fig. 6). The dural
venous sinuses were patent. The ophthalmic, occipital emissary,
and frontal diplo ic veins were opacified, and the d ip lo ic veins were
enlarged as well (Fig. 6). Pneumoencephalography demonstrated an
air-f il led intrasellar cistern, a remodeled pituitary gland, a posteriorly
positioned opt ic chiasm, and normal ventr icular anatomy (Fig. 7).
There was no evidence of a temporal or subtemporal mass. The pa
tient was discharged without addit ional 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 per formed
three years earlier for i rregular menstrual bleeding. Due to question
able papil ledema, a lumbar puncture was performed and a skull se
ries was obtained. The cerebrospinal f luid opening pressure was 195
mm Hg. Endocrinologic tests were normal. The skull ser ies demon
strated an enlarged sella turcica with a demineral ized lamina dura
(Fig. 8). Pneumoencephalography documented an empty sella turci
ca (Fig. 9). Bilateral carotid angiograms were normal.
Four years later the pat ient was evaluated for cerebrospinal fluid
rhinorrhea which developed following the ab rupt remission of a
three-week episode of severe headaches. A skull series demon
strated a twofold increase in the vo lume of the sella as well as ero
sion of the lamina dura (Fig. 10). Pneumoencephalography recon
f irmed the empty sella turcica (Fig. 11) and 111In_DTPA cisternogra
phy documented CSF rhinorrhea (Fig. 12). The cerebrospinal f luid
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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
jec tions. 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 theintrasellar c is tern out lines the sur face of the remodeled p itui tary
gland (large arrows). The poster ior 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 intracrania l 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 f indings 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 lam ina dura is demineralized (large arrow)
and the sella turcica is greatly expanded, now measuring 3,230 mm3
in volume. The small arrows i nd icate the anter ior limit of the sella
turcica.
tlon, there was evidence of increased intracranial pres-
sure. The posterior position of the optic chiasm and the
f ree access of cflr to the intrasellar c istern suggested a
deficient diaphragma sellae (17), while the enlargement
of the occipital emissary vein was evidence of increased intracrania l 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 eros ion of the lef t fo
ramina ovale and spinosum is secondary to an increase
in the caliber of the travers ing veins, as is enlargement
of the occipital emissary and frontal diploic veins.The second pat ient also had cl inical and roentgeno-
graphic findings typical of the empty sella syndrome.
The marginally elevated intracranial pressure during the
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344 CHARLES B. GROSSMAN August 1975
Fig. 9. CASE II. First admission: pneumoencephalo
gram, brow-up lateral project ion with the head hanging dem
onstrates an air-fluid level (arrows) in the intra sellar cistern.
The optic chiasm is in a posterior posit ion (single arrow).
Fig. 11. A and B. CASE II. Second admission: brow-up frontal
(A) and lateral tomograms {B) taken during pneumoencephalogra
phy. Air f il ls the intrasellar cistern (arrows). The optic chiasm is opa
cif ied (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 f irst admission of the pat ient in CASE IIand Dr. D. Gordon Potts of
The New York Hospital for his help in reviewing this manuscript.
Department of RadiologyEpiscopal HospitalPhiladelphia, Pa. 19125
REFERENCES
1. Brisman R, Hughes JEO, Holub DA: Endocrine function innineteen patients with empty sella syndrome. J Clin Endocrinol MetaboI34:570-573, Mar 1972
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Fig. 10. A and B. CASE II. Second admission: lateral (A) and
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and the sel la r volume has increased to 6,413 mm", Note the pro
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Fig. 12. CASEII. Second admission: four-hourright lateral 111In_DTPA cisternogram. There is ac
t iv ity in the int rase llar c is tern (large arrows) and
nasal mucosa (small arrows).
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