The role of internal jugular venous stenosis (IJVS) in the development of pulsatile tinnitus (PT) is unclear. In this study, we aim to assess the prevalence of IJVS and to analyze the associated imaging findings in patients with and without PT. We conducted a case-control study of consecutive adult patients with PT who underwent imaging evaluation with CT angiogram/CT venogram with contrast between February 2018 and March 2022. Age-and sex-matched controls who received CTA and/or CTV for an indication other than PT, headache, or visual disturbance were included. We compared the clinical and imaging findings between the PT and control groups. The prevalence and severity of IJVS were also analyzed. A total of 148 patients with PT and 98 control patients were included. There was no difference in the prevalence of IJVS between groups (p = 0.19). No difference in stenosis grade was observed between patients with PT and those in the control group with IJVS (p = 0.61). Empty sella turcica, optic nerve tortuosity, optic nerve sheath prominence, transverse sinus stenosis (TSS), and sigmoid sinus wall abnormalities (SSWA) were greater in the PT group than in controls (all p < 0.01). Among PT patients, imaging findings of IIH were not associated with IJVS. Among patients with IJVS, TSS and empty sella turcica were more common in PT patients than controls. IJVS was common in patients with PT and controls with similar prevalence and severity observed in both groups. TSS and SSWA were significantly more common in PT patients compared to controls. Among PT patients, there was no association between imaging findings of IIH and IJVS. Other causes of PT should be sought before considering intervention for IJVS. IIH = idiopathic intracranial hypertension; IJVS = internal jugular venous stenosis; LP = lumbar puncture; PT = pulsatile tinnitus; SSWA = sigmoid sinus wall abnormalities; TSS = transverse sinus stenosis.

Empty sella turcica (ES) is commonly observed in idiopathic growth hormone deficiency (GHD) in children. This study aims to determine the frequency of ES in children with GHD, assess their pituitary thyroid-stimulating hormone (TSH) and prolactin (PRL) reserves using the thyrotropin-releasing hormone (TRH) stimulation test, and investigate whether ES is associated with a higher prevalence of combined pituitary hormonal deficiencies. TSH and PRL pituitary reserves were assessed through the TRH stimulation test in 22 patients with ES and 31 without this finding (non-ES). All participants had childhood-onset GHD and underwent pituitary imaging, primarily by computed tomography (CT) Anti-thyroid peroxidase (anti-TPO) antibodies were measured in all patients with elevated basalTSH. Among 125 children diagnosed with GHD between 1988 and 1996, ES was identified in 29 cases (23 %). Fifty-three patients agreed to participate (86.8 % male), with ES present in 43.5 % of males and 28.6 % of females. No significant differences in TSH and PRL responses to TRH were observed between the ES and non-ES groups. Mildly elevated basal TSH was observed in 50 % of patients with ES and 55 % without ES, most of who tested negative for anti-TPO antibodies. Among patients with elevated basal TSH and hypothyroidism, the majority exhibited exaggerated or delayed TSH responses to TRH and elevated basal PRL, findings suggestive of hypothalamic dysfunction. Four patients presented combined GH, TSH, and PRL deficiencies. ES is common in children with GHD but presents distinct features compared to adults. Central hypothyroidism (CeH) was observed in 45.6 % of patients with ES and 54.8 % without ES. Mild TSH elevation was frequent and rarely associated with anti-TPO antibodies, supporting the exclusion of primary hypothyroidism and suggesting underlying hypothalamic dysfunction. Subclinical hormonal abnormalities were also frequent among euthyroid patients. The TRH stimulation test proved valuable in distinguishing hypothalamic dysfunction from pituitary or primary hypothyroidism. Genetic testing for POU1F1 and PROP1 mutations may be warranted in selected cases with combined deficiencies.

e24087 Background: Immune checkpoint inhibitors (ICIs) have transformed the prognosis of many solid malignancies. However, their use has also been associated with distinct endocrine immune-related adverse events (irAEs), hypophysitis being among the most common. Purpose: To describe in a real-world patient cohort, how ICI-induced hypophysitis is depicted on pituitary MRI and how these imaging findings are evolved overtime. Methods: A retrospective analysis of pituitary MRIs was performed on ICI-treated cancer patients who developed biochemically confirmed pituitary insufficiency from January 2016 to September 2024.The initial MRI was performed at the time of diagnosis of ICI-induced hypophysitis, and the follow-up MRI was performed at the same center and assessed by the same radiologist. Both MRIs were evaluated by a central team of radiologists, blinded to the onset of ir-hypophysitis. Results: Sixty-six ICI-treated cancer patients (median age,67 years;35 males) were biochemically diagnosed with pituitary deficiency of one or multiple axis were eligible for inclusion in our analysis. The majority received immunotherapy(70% an anti-PD-1/anti-PD-L1 ICI, and 19% anti-PD-1/anti-PD-L1 and anti-CTLA-4 combinations) for melanoma (90.9%), whereas 4.5% of cases had lung cancer, 1.5% colon cancer and 3% hepatocellular carcinoma. The initial pituitary MRI was performed on 60 patients at a median time of 2 weeks post-diagnosis of ir-hypophysitis (6 excluded due to recently administered steroids for other irAE). Abnormalities were found in 32 patients (53.3%), including enlargement (25%) or reduced enhancement of pituitary gland (10%), empty sella turcica (8.3%), heterogeneous enhancement (5%), or reduced dimensions of pituitary gland (3.3%) and slight deviation of stalk (1.7%). A 2 nd pituitary MRI assessment, after a median follow-up of 1.6 years, was available in 37 patients; 45% of them presented alteration of their initial abnormal MRI findings. Abnormalities were described in 62.2% of cases, including reduced dimensions (18.9%), or enlargement of pituitary gland (16.2%), partially empty sella turcica (16.2%), heterogeneous (8.1%) and reduced (2.7%) enhancement of pituitary gland. No ICI-regimen was associated with a specific MRI abnormality; while subjects receiving an anti-PD-1 ICI or an ICI doublet continued to show abnormal imaging at follow up in similar rates (31.8%-31.5%). Patients with multiple axes deficiencies presented an increased frequency of MRI abnormalities compared to those with isolated corticotrope deficiency in both assessments. Conclusions: MRI pituitary abnormalities were found in approximately 50% of patients with ir-hypophysitis; were not specific to the underlying malignancy and the administered ICI and may persist overtime, transforming their abnormal imaging. The other half presented normal pituitary MRI in both assessments, keeping the challenge of imaging for this irAE.

Cerebrospinal fluid (CSF) rhinorrhea is a relatively rare medical condition characterized by the drainage of CSF through the nasal cavity. Cerebrospinal fluid leakage can be attributed to a plethora of different causes, mostly traumatic or iatrogenic, but it can also be spontaneous. Due to its rare entity, CSF rhinorrhea is often a diagnostic trap and can be misdiagnosed and mistreated as rhinosinusitis or allergic rhinitis. This can result in severe complications, such as meningitis, which could potentially have life-threatening consequences if not accurately identified and managed. In this case report, a 53-year-old Caucasian woman presented at the emergency department with symptoms of headache, fever, transparent nasal discharge from her left nostril when leaning forward and mild neck stiffness. Based on the patient's clinical presentation and physical examination findings, there was a high suspicion of central nervous system infection and cerebrospinal fluid leakage. A lumbar puncture confirmed the diagnosis of meningitis, while imaging exams, including computed tomography (CT) and magnetic resonance imaging (MRI) scans, revealed a fistula between the posterior wall of sphenoid sinus and the subarachnoid space. Additional findings included an empty sella turcica, suggesting a potential underlying cause for this condition and an incidental meningioma near the area of leakage. The patient received empiric intravenous antibiotic therapy and was discharged after ten days. She was referred to the neurosurgical department for surgical repair of the CSF leak and removal of the meningioma, in line with appropriate treatment guidelines. This study highlights the importance of promptly identifying and thoroughly investigating potential causes of CSF leakage to provide appropriate medical management.

INTRODUCTION/BACKGROUND Empty sella syndrome (ESS) is characterized by the radiological finding of a flattened pituitary gland within the empty sella turcica due to subarachnoid space expansion, commonly associated with hormonal deficiencies. We report a rare case of panhypopituitarism due to primary ESS in a young female who presented with bilateral osteoporotic femur fractures. CASE A 38-year-old aboriginal female was first brought to the orthopedic team for persistent right hip pain and a limping gait for several years. There was no prior history of trauma, surgery or irradiation. CT of bilateral hip joints showed generalized osteopenia with non-union bilateral femur fracture. Bone mineral density revealed osteoporosis of the lumbar spine and left radius with Z-score of -4.3 and -6.6, respectively. Further evaluation for secondary osteoporosis revealed short stature with a low BMI of 17 kg/m2. Notably, she has primary amenorrhea and delayed puberty, with Tanner stage 1 breast and pubic hair development. Family history was unremarkable except for one younger sister with short stature. Anterior pituitary hormone profile revealed central hypothyroidism (TSH: 2.05 mIU/L, fT4: 6.7 pmol/L), hypogonadotrophic hypogonadism (serum estradiol &lt;55.1 pmol/L, FSH: 0.3 IU/L, LH &lt;0.2 IU/L), low prolactin (35.7 mIU/L) and low IGF-1 level of 11.9 ng/ml (69 -227 ng/ml) suggestive of growth hormone deficiency. Additionally, her vitamin D level was insufficient, 68.79 nmol/L. Short Synacthen test revealed adequate cortisol response. MRI of pituitary reported features of empty sella, confirming the diagnosis of primary ESS. She received hormonal replacement therapy, including estradiol, for pubertal induction. She was counselled for right total hip replacement, but she was not keen. CONCLUSION Panhypopituitarism observed in ESS affects bone remodeling, leading to early osteoporotic fracture. Treatment with hormonal replacement is essential to restore secondary sexual characteristics for psychosocial well-being as well as to improve bone health to reduce the risk of further fracture.

Background: Idiopathic Intracranial Hypertension (IIH) is characterized by elevated intracranial pressure (ICP) without identifiable etiology. While Magnetic Resonance Imaging (MRI) often reveals findings such as empty sella turcica, optic nerve abnormalities, and transverse sinus stenosis, their correlation with cerebrospinal fluid (CSF) pressure remains unclear. Objective: To investigate the correlation between MRI abnormalities and lumbar opening and closing pressures in patients with IIH. Methods: A cross-sectional study was conducted with 21 IIH patients diagnosed using the Modified Dandy Criteria over five years. MRI findings were categorized as normal or abnormal (empty sella, optic nerve abnormalities, and transverse sinus stenosis), and their association with lumbar opening and closing pressures, measured during the initial lumbar puncture, was analyzed using Student's T-test. Results: No statistically significant differences in lumbar opening or closing pressures were observed between patients with normal and abnormal MRI findings (P = 0.605 and P = 0.778, respectively). Similarly, no significant associations were identified for optic nerve abnormalities (P = 0.494 and P = 0.522), venous sinus abnormalities (P = 0.356 and P = 0.370), or empty sella turcica (P = 0.685 and P = 0.591). Conclusion: The study found no significant correlation between MRI findings and CSF pressures in IIH patients. These results align with existing literature, suggesting that MRI findings alone may not adequately predict CSF pressure levels. Alternative diagnostic methods, such as optical coherence tomography, may be more sensitive in detecting early optic nerve abnormalities.

This article reviews a rare case of Sheehan's syndrome in a 40-year-old female patient, confirmed by magnetic resonance imaging (MRI) after the onset of adenohypophyseal insufficiency, prolonged amenorrhea, and hypoglycemic crises. Sheehan's syndrome, a rare postpartum complication, is caused by pituitary necrosis following severe postpartum hemorrhage. The patient presented with hormonal deficiencies affecting the thyroid, adrenal, and gonadal axes. MRI findings showed a partially empty sella turcica and pituitary atrophy, which confirmed the diagnosis. The article discusses the clinical presentation, diagnostic imaging, and the role of MRI in early identification and management of Sheehan's syndrome, emphasizing the importance of timely interventions to prevent complications associated with hypopituitarism.

ObjectiveThis study investigated the prevalence and association of magnetic resonance imaging (MRI) imaging markers indicative of idiopathic intracranial hypertension (IIH) in patients diagnosed with endolymphatic hydrops (EH). The objective was to elucidate potential pathophysiological links between inner ear fluid dysregulation and alterations in intracranial pressure.MethodsA total of 108 adult patients with dedicated MRI and delayed post-contrast (hydrops) sequences obtained for assessment of auditory/vestibular symptoms between 01/2020 and 06/2025 were retrospectively reviewed. EH grading, nerve volumes of the cochlear nerve, common vestibular trunk and facial nerve, IIH imaging features (e.g., Meckel’s cave dilatation, optic nerve findings, venous sinus stenosis), and clinical symptoms were recorded. The prevalence and co-occurrence of EH and IIH features were statistically analyzed.ResultsVestibular EH (grade 2) was noted in 71.3% (right) and 60.2% (left) of patients and cochlear EH (grade 2) in 42.6% (left) and 34.3% (right) of patients. IIH-related imaging markers were common: bilateral Meckel’s cave dilatation (60.2%), partially empty sella turcica (50.9%), bilateral optic nerve sheath dilation (57.4%), optic nerve head enhancement on delayed FLAIR sequences (67.6%), and intrinsic bilateral transverse sinus stenosis (26.9%). Statistically significant associations were identified between vestibular EH severity and optic nerve sheath dilation (p = 0.0368), optic nerve tortuosity (p = 0.0309), slit-like lateral ventricles (p = 0.0023), and increased subcutaneous fat thickness in the scalp and neck (p = 0.003). Conversely, intrinsic bilateral transverse sinus stenosis was negatively correlated with EH severity (ρ = −0.228, p = 0.017). Overlap analyses demonstrated that many patients with moderate to severe EH exhibited multiple IIH imaging features concomitantly.ConclusionMRI findings demonstrate a frequent coexistence of EH and radiological biomarkers of IIH. This observation supports a potential pathophysiological association between inner ear fluid dysregulation and elevated intracranial pressure, underscoring the need for prospective studies integrating clinical outcomes with advanced MRI-based assessments of fluid dynamics.

Abstract Disclosure: P. Vemparala: None. S. Challagulla: None. Introduction: Hyponatremia is a common electrolyte disorder with potentially life-threatening consequences. Careful evaluation of hyponatremia can uncover significant underlying conditions. We present an interesting case of a patient who presented with symptoms of severe hyponatremia and a workup led us to the discovery of empty sella syndrome as the etiology. Case Presentation: A 54-year-old male with hypertension presented with 2 days of left-sided headache, blurred vision, generalized weakness, and vomiting. Pertinent medication history revealed the use of thiazide diuretic, bupropion and varenicline. Physical examination was unremarkable. Laboratory data showed severe hyponatremia with a serum sodium of 118 meq/L. Initial improvement with fluids was followed by a decline (106-112 meq/L). CT head without contrast showed a prominent empty sella turcica. Workup revealed urine osmolality and elevated urine sodium. A low AM cortisol level of 1.0 mcg/dl (reference range- AM- 7.0 - 25.0 mcg/dl), and decreased adrenocorticotropic hormone (ACTH) level of 5.2 pg/ml (reference range- 7.2 - 63.3 pg/ml) suggested secondary adrenal insufficiency. All other anterior pituitary hormones were normal. Brain magnetic resonance imaging (MRI) confirmed the diagnosis of partial empty sella. Treatment with hypertonic saline, fluid restriction, and steroids led to symptom resolution. Conclusion: Empty sella syndrome is a rare pituitary condition that can be primary- characterized by herniation of the subarachnoid space within the sella, or secondary- which occurs when the sella is empty due to damage to the pituitary gland by tumor, radiation, etc. It can cause potential hypopituitarism, be asymptomatic, or present with symptoms of raised intracranial pressure. In patients with hypopituitarism, deficiencies of ACTH and TSH are rarer and appear to be more common with a complete empty sella. This case emphasizes the need for a comprehensive hyponatremia workup, awareness of secondary adrenal insufficiency, and recognition of the life-threatening potential of even partial empty sella syndrome when untreated. Presentation: 6/1/2024

Abstract Disclosure: M.S. Tkach: None. A. Pinero-Pilona: None. A 74-year-old woman diagnosed with a pituitary mass, described as a prolactinoma, presented for follow-up care with elevated prolactin (“PL”). Initial diagnosis of a prolactinoma was 46 years prior to presentation. Prior imaging was not available. She received bromocriptine for 31 years; as PL increased to 90 on a drug holiday, bromocriptine was resumed for over a decade. After that time, PL decreased to 23, 11 years later. She was switched to cabergoline after reporting a “stuffy nose”. With PL up to 37.8 two years later, cabergoline was increased to 0.5 mg one tablet twice a week. PL subsequently dropped to 8.2 over the next two years. Upon presentation, she reported no brain imaging for “over 30 years”. She denied galactorrhea, headache, sweating, nausea, weight change, severe hypertension, hypotension, diabetes, hirsutism, fatigue, or muscle weakness. She denied visual field changes, or any formal visual field testing for over 20 years. Exam on initial presentation was unremarkable except for a diffuse goiter. Initially ordered labs were unremarkable, though A1c was 6.2%. Undiluted PL was 6.0 (confirmed on 1:100 dilution). Another PL was measured at 4.6 total and 3.8 monomeric. TSH was 1.47. Thyroglobulin antibodies and TPO were undetectable. On pituitary MRI, "the pituitary gland shows a partially empty sella turcica which is asymmetrically slightly outwardly convex on the right, possibly representing an occult arachnoid cyst versus cystic adenoma. There is a midline pituitary stalk. No parasellar abnormalities.” Scalloping of the right sellar portion was noted. Cystic changes in the pituitary in this case may be related to cystic prolactinoma, arachnoid cysts, or cystic degeneration of a prolactinoma after long-term treatment with a dopamine agonist. Cystic prolactinomas have been termed “transitional cell tumors of the pituitary” as they possess both Rathke cleft cyst and prolactinoma features. Reduced efficacy of response to medical as compared to surgical therapy in these patients has been observed. They also tend to lead to lower PL levels than solid prolactinomas, complicating diagnosis. Arachnoid cysts (“AC”) are collections of CSF within the arachnoid membrane: present in about 1.7% of the population, they account for about 1% of intracranial masses. Although an uncommon location, sellar AC have been previously described and are estimated to comprise about 3% of AC. Nonfunctioning pituitary masses or AC with stalk compression can cause elevated PL; these respond to dopamine agonist therapy, though it is not considered definitive therapy in the case of a nonfunctioning adenoma. This case represents the difficulties in management and transition of long-term care and treatment of prolactinomas as well as assessing pituitary radiological findings. Presentation: 6/1/2024

Abstract Disclosure: F.S. Rodrigues: None. C.C. Silva: None. W. Da Silva: None. T.M. Caldas: None. L. Rocha: None. Introduction: Sheehan's Syndrome, or postpartum hypopituitarism, is characterized by hyperplasia and an increase in the number of prolactin-secreting cells, secondary to a major hemorrhagic event occurring during or after childbirth. In this situation, the anterior pituitary gland can increase in size and suffer ischemia due to vascular hypoflow. Consequently, there is low production of one or more of the hormones produced by the gland, which can generate heterogeneous clinical presentations. As a preventive treatment, polytransfusion is recommended in cases of large hemorrhage. OBJECTIVE: To present a case of Sheehan’s Syndrome, which developed after a birth complicated by a major hemorrhagic event, even after receiving polytransfusion. CASE REPORT: A woman, 45 years old, being monitored at the endocrinology outpatient clinic for 2 years. As a history, there was a severe hemorrhage during her cesarean section, which occurred 30 years ago, in which she received a blood transfusion of a total of 1.2 liters of packed red blood cells. 7 years ago, she was diagnosed with hypothyroidism and 2 years ago with hyperprolactinemia. In 2022, she was also diagnosed with adrenal insufficiency. At that time, she underwent a magnetic resonance imaging (MRI) scan of the sellaturcica region, which was found to be partially empty. The patient's recent exams showed TSH: 3.15 μUI/mL (0.4-4.0); Free T4: 0.88 ng/dL (0.93-1.7); Cortisol 8h: 8 μg/dL (5-25); LH: 15 mIU/mL (1.1-14.7); FSH: 43 mIU/mL (2.8-9); Estradiol: 8 ng/dL (12.4-398); Prolactin: 28 ng/mL (1.9-25), basal GH 0’ 0.054/30’ 2.51/60’ 2.48/90’ 3.74 ng/mL (up to 10), ACTH 17 pg/mL (up to 46). Since then, she has been undergoing endocrinological monitoring for hormone replacement therapy to treat the hormonal changes caused by late-diagnosed Sheehan Syndrome. DISCUSSION: Sheehan's Syndrome is a rare disease, characterized by low blood flow and necrosis of the pituitary gland due to postpartum hemorrhage. The diagnosis results from obtaining a good clinical history associated with hormonal levels. This patient presented significant bleeding after cesarean section requiring transfusions. However, despite transfusions, the patient developed hypothyroidism, hyperprolactinemia, and adrenal insufficiency. The MRI confirmed the suspected diagnosis, showing the partially empty sellaturcica. Conclusion: The diagnosis of Sheehan Syndrome is based on very broad clinical manifestations, with MRI of the sellaturcica contributing to confirming the diagnosis. Although the preventive treatment is blood transfusion, the patient developed the disease, highlighting the need for continued monitoring of pregnant women with a history of significant bleeding during childbirth. Therefore, outpatient monitoring of the patient is necessary with a focus on hormonal levels so that clinical complications are avoided. Presentation: 6/2/2024

Idiopathic intracranial hypertension (IIH) is a rare neurological disorder in the pediatric population which is defined as an increase in intracranial pressure (ICP) without the presence of brain parenchymal lesions, hydrocephalus, or central nervous system infection. In this study, we have determined the magnetic resonance imaging (MRI) findings in IIH patients. A comprehensive literature search was conducted using the electronic databases including Web of Sciences, Scopus, and Pubmed to identify suitable and relevant articles using keyword search methods. The search included keywords such as "idiopathic intracranial hypertension," "pseudotumor cerebri," "MRI," and "pediatrics." The search was limited to the available publications up to January 2024. MRI plays a crucial role in diagnosing IIH by excluding secondary causes and revealing neuroimaging findings associated with elevated ICP. Despite fewer studies in children compared to adults, MRI serves as a cornerstone in identifying traditional neuroradiological markers such as empty sella turcica, posterior globe flattening, optic nerve tortuosity, optic nerve sheath distension, and transverse venous sinus stenosis. Additional subtle markers include increased Meckel's cave length, cerebellar tonsillar herniation, and slit-like ventricles, although these are less reliable. Diffusion-weighted imaging does not typically show cerebral ADC value changes indicative of cerebral edema in pediatric IIH. MRI findings provide valuable non-invasive diagnostic indicators that facilitate early detection, clinical management, and potential surgical intervention in pediatric IIH. The reliability of these MRI markers underscores their importance in clinical practice.

Sheehan's syndrome or postpartum anterior pituitary necrosis results in pan hypopituitarism. This is an ischemic necrosis of the anterior pituitary gland secondary to a state of sudden shock during a postpartum hemorrhage. It is a serious complication of the postpartum period. Advances in obstetric care in developed countries have reduced the incidence of this disease. In black Africa its frequency is unknown with a few reported cases. The authors report 4 cases of Sheehan's syndrome treated at the Hôpital Principal de Dakar. This is a retrospective study carried out in the medical departments of the main hospital of Dakar over 5 years. Secondary amenorrhea of variable duration 1 to 10 years was noted in 3 patients. Clinical presentation consisted of a worsening in the general condition in all patients. Low cortisol levels were noted in most patients associated with an empty sella turcica on pituitary MRI. The outcome was favorable under treatment.

Background: The pituitary gland is prone to various lesions, and the endoscopic transsphenoidal approach is a minimally invasive surgical technique for removing such lesions. Surgical removal of part or all pituitary lesions can result in an empty sella turcica, potentially causing herniation of the optic chiasm. This report presents three cases of patients who developed visual impairment following pituitary surgery and were diagnosed with herniation of the optic chiasm into an empty sella turcica. Case Series: We report three cases of visual deterioration following transsphenoidal resection, with MRI findings indicating optic chiasm herniation. These cases underscore the complexity of post-surgical outcomes and the potential mechanical impact on the optic chiasm. Case 1: A 65-year-old man underwent surgery for a Rathke’s cleft cyst, resulting in initial unchanged vision, followed by worsening bitemporal hemianopia despite successful cyst removal. Post-operative imaging suggested optic chiasm herniation, with subsequent hormonal disturbances developing 4 weeks after surgery. Case 2: A 62-year-old man with a history of macroprolactinoma, initially treated with dopamine agonists, experienced progressive vision loss despite medical therapy, leading to surgical intervention. Post-surgery, prolactin levels improved, but visual acuity continued to decline, with imaging showing persistent optic chiasm herniation 6 weeks post-operation. Case 3: A 37-year-old man, previously treated for a pituitary adenoma via transsphenoidal surgery, presented with worsening bitemporal hemianopia 96 weeks post-surgery. MRI revealed downward traction of the optic chiasm, suggesting long-term mechanical effects impacting vision. Conclusion: This case series highlights that patients presenting with visual changes and a history of recent pituitary gland surgery should be investigated for herniation of the optic chiasm into the sella turcica.

Oral and maxillofacial surgeons frequently encounter various anatomical abnormalities and incidental discoveries while reviewing routine radiographs. These serendipitous findings can ultimately benefit the patient by enhancing our diagnostic practices and facilitating timely treatment. This report aims to spotlight a noteworthy radiological finding known as "Empty Sella Syndrome" (ESS) and present a case report from our department. ESS involves the compression of the pituitary gland into a thin rim due to increased cerebrospinal fluid pressure, resulting in the appearance of an almost empty sella turcica. This condition impacts both the neurological and endocrine systems in individuals of all age groups, exhibiting a preference for females. A young patient reported with Buccal space infection and drainage of pus extra-orally along with decayed teeth. The treatment planned was Incision &amp; Drainage, extraction of non-restorable teeth under General Anesthesia as it was a challenge to make the patient cooperate under local anesthesia due to her social anxiety and comprehension difficulties. Patients with empty sella syndrome who present with hormonal deficiencies and delay in developmental milestones may experience intellectual disabilities, they require multidisciplinary collaboration, long term treatment and observation. A thorough knowledge of human anatomy and interpretation of radiographs as well as investigations is critical in recognizing such rare and unusual conditions.

Community-acquired bacterial meningitis in adults represents one of the most severe infectious diseases worldwide with potentially life-threatening medical complications. Several infectious agents can cause acute meningitis. Although group B Streptococcus is more prevalent in newborns, infection can also lead to meningitis in older adults, particularly those with underlying health issues. A 53-year-old woman with a body mass index of 28.7 kg/m2, type 2 diabetes mellitus, and dyslipidaemia presented to the emergency department of Santa Maria della Stella Hospital (Orvieto, Italy) with confusion, low-grade fever, echolalia, and hyperglycaemia. Computed tomography scans of the brain revealed a hypodensity in the left anterior frontal lobe and an osteodural defect of the rhinobase. Meningitis was suspected and empiric broad-spectrum antibiotic therapy with corticosteroids and insulin were administered while the results of the cerebrospinal fluid analysis confirmed the diagnosis of group B Streptococcus meningitis. Repeat imaging at 48 hours revealed enlargement of the hypodense lesion. The frontal assessment battery indicated deficits in executive functions. Prompt treatment led to rapid clinical improvement. Following the restoration of euglycemic status and hemodynamic stabilization, a follow-up magnetic resonance imaging confirmed the ischaemic lesion and showed cerebrospinal fluid in the sella turcica. The patient was then transferred to neurorehabilitation. The complex interactions among multiple risk factors resulted in an atypical clinical case of group B Streptococcus meningitis, which was promptly treated with empiric antibiotic therapy to mitigate neurocognitive deficits. Group B Streptococcus can cause meningitis in adults with poorly controlled type 2 diabetes mellitus and should be promptly treated with empiric broad-spectrum antibiotics.An osteodural defect of the ethmoid roof together with idiopathic intracranial hypertension may result in empty sella turcica and CSF rhinorrhoea, promoting the dissemination of the pathogen.Meningitis patients with pre-existing diabetic cerebral vasculopathy may develop cerebrovascular complications and cognitive impairments.

Osteomeningeal breach is a discontinuity in the osteomeningeal layer that allows cerebrospinal fluid to flow into an air-filled cavity at the base of the skull. Its severity is associated with the risk of central nervous system infection. The majority of breaches are traumatic in origin, either accidental or iatrogenic. Spontaneous cerebrospinal fluid rhinorrhea is less commonly found. Obesity, often coupled to obstructive sleep apnea syndrome, can lead to hypercapnia, increasing the pressure of cerebrospinal fluid and thereby facilitating the development of osteomeningeal breaches. In cases of intracranial hypertension, the displacement of the pituitary gland can occur, and as a result, its cavity can be filled with cerebrospinal fluid, which characteristically describes an empty sella turcica syndrome. We present the case of a 52-year-old woman initially admitted for the management of sleep apnea syndrome, along with a history of chronic rhinorrhea. Analysis of the rhinorrhea fluid and craniofacial imaging revealed a cerebrospinal fluid leak through a breach in the right cribriform plate, associated with an empty sella turcica syndrome. The patient underwent surgical repair of the meningeal breach via an endonasal approach, leading to a successful resolution of cerebrospinal fluid rhinorrhea.

Adrenal insufficiency is a critical condition that can often present with non specific symptoms, posing a diagnostic challenge in the context of co-existing conditions. Authors hereby, report a complex case of secondary adrenal insufficiency revealed through persistent fever and hyponatremia in a 73-year-old female with a multifaceted medical history, including hypertension, diabetes, and Takotsubo cardiomyopathy. Her symptoms of intermittent fever and diarrhoea were refractory to treatment, leading to hospital readmission. Initial laboratory investigations highlighted hyponatremia, low haemoglobin, elevated inflammatory markers, and low cortisol levels. Although a urinary tract infection with multidrug-resistant Klebsiella was identified and treated, her febrile state persisted. Extensive serological testing for a broad range of infectious diseases yielded negative results, excluding infectious etiologies as the cause of her fever. Imaging studies, including chest X-ray, Electrocardiogram (ECG), echocardiogram, Positron Emission Tomography (PET) scan, Computed Tomography (CT), and transesophageal echocardiography, failed to identify a source of infection or malignancy. Notably, a low random cortisol level coupled with an inappropriately low Adrenocorticotropic Hormone (ACTH) level prompted further endocrine evaluation. Magnetic Resonance Imaging (MRI) revealed an empty sella turcica, confirming secondary adrenal insufficiency. This diagnosis was substantiated by the patient’s positive response to steroid therapy, which led to clinical improvement and eventual discharge. The present case underlines the importance of considering adrenal insufficiency in patients presenting with unexplained hyponatremia and fever, particularly when other common aetiologies have been ruled out. It also illustrates the potential for critical endocrine disorders to mimic sepsis, underscoring the necessity of a comprehensive diagnostic approach in the face of complex presentations.

Objective: To describe the clinical, radiological characteristics and outcomes of patients with Idiopathic intracranial hypertension (IIH) at 6 months in a cohort of South Indian patients. Methods: We did a prospective study on patients presented to our institute with the symptomatology of IIH. A detailed history regarding headache, visual symptoms were noted. A complete neurological examination including examination of the fundus, CSF opening pressure, MRI brain, and MR cerebral venography were performed for all subjects. The patients were followed-up for 6 months to assess treatment response. Results: We evaluated 49 patients, the majority were females, and 38.7% had grade 1 obesity. Headache was the most common clinical presentation. The most common MRI abnormality was empty sella turcica, noted in 47%. There was a significant positive correlation between CSF opening pressure and headache severity (R2= 0.165, p = 0.018), as well as between CSF opening pressure and the grade of papilledema (R2=0.245, p=0.001). Of the cases, 95% responded to medical management, and three patients of fulminant IIH underwent lumbar-peritoneal shunting. At 6 months, 60% had persistent headaches. Only 8.7% had persistent visual symptoms, and only one had optic atrophy. There was no significant correlation between the follow-up grade of papilledema and the patient’s BMI. No significant correlation was found between the amount of weight lost and the improvement in the Numerical Rating Scale (NRS) score at 6 months. Conclusion: Headache in IIH is multifactorial and a significant cause of disability. The overall prognosis for vision is good. IIH should be suspected in any obese woman with headaches since it is one of the preventable causes of blindness.

Rarely has empty sella syndrome been documented in children, and radiographic imaging frequently identifies subarachnoid herniation through the sellar diaphragm and pituitary gland compression. In this correspondence, we report the discovery of an empty sella turcica on a brain magnetic resonance imaging (MRI) of a short 5-year-old kid. He identified hypopituitarism in form growth hormone deficiency and central adrenocortical insufficiency but normal thyroid function `during neuroendocrine examination of hypothalamic-pituitary function. Before beginning growth hormone therapy, this knowledge is essential to prevent the dangerous effects of an adrenal crisis. This matter was brought to light.