Suprasellar Research Articles

A narrative review of magnetic resonance imaging findings in pediatric idiopathic intracranial hypertension.

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.

Ophthalmologic symptoms as the first manifestation of primary complete empty sella syndrome- case report

Background: Empty sella syndrome (ESS) is a rare condition associated with loss of pituitary gland volume. ESS has a heterogeneous clinical manifestation including endocrine, neurological, and visual deficits. The most common symptoms include chronic headaches and hormonal disturbances associated with hypopituitarism.Aim of the study: To emphasize the role of ophthalmologists in the initial management of intracranial hypertension and the significance of a multidisciplinary approach in the management of ESS.Case report: Primary complete ESS was reported in a 32-year-old male presenting nonspecific ophthalmologic symptoms including ophthalmalgia and subjective worsening of the visual acuity. The ophthalmological exam revealed bilateral optic disk elevation. The subsequent MRI identified a suprasellar cistern invaginating within sella turcica with resulting pituitary gland flattening. A complete empty sella syndrome was confirmed. In addition, idiopathic intracranial hypertension was suspected. The patient was proposed hospitalization in the neurology department for additional testing however, he refused due to personal reasons.Conclusions: To date, only a few papers reported ESS with preliminary ophthalmological symptoms. All patients with nonspecific eye symptoms should have a complex ophthalmological examination. Bilateral optic disk elevation requires urgent imaging of the brain and orbits, and the golden-standard approach remains MRI. During the diagnostic process, the secondary causes of intracranial hypertension including tumor, bleeding, abscess, hydrocephalus, or venous sinus thrombosis must be excluded. Due to the heterogeneous clinical course of ESS, patients require multidisciplinary management and follow-up by endocrinologists, neurologists, neurosurgeons, and ophthalmologists.

Retrospective analysis of the upper airway anatomy and Sella turcica morphology across different skeletal malocclusions: a computerized technique

ObjectiveThis study aimed to investigate the normal volumetric space and variations in the measurements of different landmarks in adults with different skeletal relations of the maxilla and the mandible based on CBCT data. The study also analyses these landmarks to locate any correlations.BackgroundNumerous studies in orthodontics have found a relationship between orthodontic treatment and changes in the anatomy and function of the airway. Severe changes in airway morphology can cause breathing difficulties, lower quality of life, and even result in life-threatening conditions such as obstructive sleep apnoea. Consequently, orthodontic diagnosis and treatment planning require a thorough understanding of the airway space and its function.MethodsThe present retrospective study was conducted using CBCT records of 120 adult patients, containing 40 samples of each skeletal class (20 males and 20 females). The boundaries were defined for the 3 major regions: the nasopharynx, the oropharynx, and the hypopharynx. Various measurements were recorded across these regions, as well as selective cephalometric landmarks. The obtained data was used to calculate average and standard deviation, while regression analysis was used to evaluate correlations and t-test was used to test statistical significance of gender differences.ResultsThe results demonstrate that skeletal Class III individuals exhibit a reduced airway volume in the nasopharynx compared to other groups, whereas skeletal Class II individuals displayed a diminished airway volume in the hypopharynx. A strong correlation was observed for Sella turcica parameters. There were no significant differences in skeletal parameters across genders. Nasopharynx cavity volume demonstrated significant differences between skeletal Class I–Class III as well as between skeletal Class II–Class III. Hypopharynx cavity volume also demonstrated significant differences between skeletal Class I–Class II and between skeletal Class II–Class III.ConclusionThe major findings are the presence of a reduced nasopharyngeal volume in skeletal Class III malocclusions while skeletal Class II individuals displayed a diminished hypopharyngeal volume, making these critical areas to consider during the diagnostic and orthodontic treatment planning stages. This study also revealed a consistent correlation between Sella turcica parameters across various facial skeletal profiles, with skeletal Class II patients exhibiting a distinct pattern and skeletal Class I and Class III demonstrating an average relationship.

Protocolo diagnóstico del síndrome de la silla turca vacía

Empty sella is a radiologic finding in which the sella turcica appears empty due to cerebral spinal fluid within the subarachnoid space herniating. Today, this finding is relatively common, this proportion increases with aging, and is more prevalent in women. It has been historically thought that empty sella is an incidental finding without clinical significance that does not require further monitoring or treatment. However, some patients will have endocrine or neurologic consequences. Symptoms in this clinical condition can include headache or vision loss associated with idiopathic intracranial hypertension, hyperprolactinemia or hypopituitarism. Symptomatic patients should be treated with pharmacologic to surgical therapies.

Correlation of Clivus Length and Angle with Chronological Age, Gender, Sagittal Growth Pattern of the Jaws, and Skeletal Maturation Using Lateral Cephalometry.

Determination of remaining growth potential of patients is the most important factor in orthodontic treatment. This study aimed to assess the correlation of clivus length and angle with age, gender, sagittal growth pattern of the jaws, and skeletal maturation using lateral cephalometry. This cross-sectional study was conducted on 390 lateral cephalograms (Vatech, paX-i3D Green, South Korea) of patients aged 6 to 25 years. The patients were assigned to three groups of skeletal class I, II, III (n=130) with equal gender distribution. The clivus length and angle, Welcher angle, maxillary and mandibular effective length, sella turcica to Nasion (SN), and the angles between SN and point A (SNA), between SN and point B (SNB), and between NA and NB (ANB )were measured. Correlations of variables with age and gender, and cervical vertebral maturation stage (CVMS) were analyzed using the Pearson and Spearman's correlation tests, independent t-test, and one-way ANOVA at 0.05 level of significance. Clivus length had a significant correlation with SNA (r= 0.103, p= 0.042), SNB (r= 0.108, p= 0.033), maxillary (r= 0.547, p< 0.001) and mandibular (r= 0.589, p< 0.001) effective lengths, SN length (r= 0.586, p< 0.001), and CVMS (r= 0.697, p< 0.001). Clivus angle had a significant correlation with SNA (r= 0.105, p= 0.039), SNB (r= 0.155, p= 0.002), maxillary (r= 0.507, p< 0.001) and mandibular (r= 0.596, p= 0.001) effective lengths, SN length (r= 0.566, p< 0.001), and CVMS (r= 0.699, p< 0.001). The mean clivus length (p= 0.006) and angle (p= 0.002) were significantly higher in males, and had a significant correlation with age (r= 0.636 and r= 0.718, p< 0.001). The mean clivus length and angle were not significantly different in class I, II, III (p> 0.05). All parameters were greater in males, and increased with age (except Welcher angle). Clivus length and angle had significant correlations with position of both jaws but not with sagittal relationship.

Sheehan's syndrome. A descriptive study of 4 cases at the main hospital of Dakar

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.

Evaluation of Sella Turcica Bridging, Ponticulus Posticus Calcification and Sella Turcica Volume in Individuals with Different Malocclusions

Evaluation of Sella Turcica Bridging, Ponticulus Posticus Calcification and Sella Turcica Volume in Individuals with Different Malocclusions

How successful is the CatBoost classifier in diagnosing different dental anomalies in patients via sella turcica and vertebral morphologic alteration?

BackgroundTo investigate how successfully the classification of patients with and without dental anomalies was achieved through four experiments involving different dental anomalies.MethodsLateral cephalometric radiographs (LCRs) from 526 individuals aged between 14 and 22 years were included. Four experiments involving different dental anomalies were created. Experiment 1 included the total dental anomaly group and control group (CG). Experiment 2 only had dental agenesis and a CG. Experiment 3 consisted of only palatally impacted canines and the CG. Experiment 4 comprised patients with various dental defects (transposition, hypodontia, agenesis-palatally affected canine, peg-shaped laterally, hyperdontia) and the CG. Twelve sella measurements and assessments of the ponticulus posticus and posterior arch deficiency were given as input. The target was to distinguish between anomalies and controls. The CatBoost algorithm was applied to classify patients with and without dental anomalies.ResultsIn order from lowest to highest, the predictive accuracies of the experiments were as follows: experiment 4 < experiment 2 < experiment 3 < experiment 1. The sella area (SA) (mm2) was the most important variable in experiment 1. The most significant variable in prediction model of experiment 2 was sella height posterior (SHP) (mm). Sella area (SA) (mm2) was again the most relevant variable in experiment 3. The most important variable in experiment 4 was sella height median (SHM) (mm).ConclusionsEvery prediction model from the four experiments prioritized different variables. These findings may suggest that related research should focus on specific traits from a diagnostic perspective.

VARIABILITY REGULARITIES OF THE CEPHALOMETRICAL PARAMETERS OF THE HUMAN FETAL SKULL

The purpose of the study – to find out the regularities of the age dynamics of cephalometricparameters and critical periods of the development of the skull of human fetuses.Material and methods. 60 preparations of skulls and 63 computer tomograms of theheads of human fetuses aged from 4 to 10 months of intrauterine development werestudied. A complex of morphological research methods was applied, which includedanthropometry, morphometry, three- dimensional reconstruction and statistical analysis.Linear and angular parameters of the skull were measured, and their ratios, characterizingthe constitutional and cephalometric parameters of the individual (cranial and facialindices), were determined. Results. The analysis of absolute cephalometric parameters (longitudinal, transversediameters, skull circumference, height dimensions) demonstrated the predominanceof logarithmic dynamics of their changes in human fetuses, that is explained by theiraccelerated growth during the 4th month of intrauterine development and a slowdownduring the 7th month with subsequent acceleration in the 8th month of prenatal development.A straight trend line is characteristic of the V-S height (distance from the Sella turcica tothe highest point of the skull), which is explained by the accelerated growth of the anteriorand posterior cranial fossae, while the sphenoid bone and the region of anterior fontanelledevelop in a consistent direction and pace. The linear pattern of growth is typical for theforamen magnum, hard palate, length of the orbit, body and ramus of the mandible, aswell as for relative cephalometric parameters that show a wide range of morphometricvariability. Analysis of the scatter diagram using the method of weighted least squaresdistances showed a decrease in the angle of the front part of the cranial base until the5th month of intrauterine development, followed by an increase in the 7th-8th months ofprenatal development. Multivariate regression analysis of the relationship between fetalage, cranial index and the value of the angle of the front part of the cranial base showedpronounced anatomical variability, which depended on the craniotype. Before the end ofintrauterine development, the N-S-Ba angle increases, but at the beginning of the fetal periodof ontogenesis, it decreases. It has the smallest values in dolichocephals compared to othercraniotypes. The largest values of this angle are found in mesocephals at the beginning of thefetal period, and in brachiocephals and mesocephals at the end of intrauterine development.Conclusions. 1. Critical periods of skull development in the fetal period of humanontogenesis are the 4-5th and 7-8th months, during which uneven changes in absoluteand relative craniometric parameters are observed. 2. The value of the angle of the frontpart of the cranial base can be a diagnostic and prognostic indicator in combinationwith the cranial index, which characterize the craniotype of the individual, during themonitoring of the normal development of the skull and brain of the fetus.

Collision of pituitary neuroendocrine tumor and anterior clinoid meningioma treated with a two-stage minimally invasive surgical strategy: illustrative case.

The locations of pituitary neuroendocrine tumor (PitNET) and anterior clinoid meningioma (ACM) appear to be very close but essentially different, as the former is inside the sella turcica while the latter is in the intradural space. A collision tumor thus requires a specific treatment strategy but has been rarely reported. A 77-year-old woman presented with progressive visual impairment due to significant compression of the optic apparatus by a collision of PitNET and ACM. With a minimally invasive two-stage therapeutic strategy, the ACM was first resected using an endoscopic mini-pterional approach, then the PitNET was removed with an endoscopic transnasal approach 8 weeks later, leading to significant improvement in visual function. The authors' literature search identified only 2 documented cases of a similar collision. This case underscores the complexity of the decision-making process in the management of collision tumors and suggests the potential benefit of staged minimally invasive surgical interventions in preserving visual function. Further accumulation of cases is warranted for refining the treatment strategy. https://thejns.org/doi/10.3171/CASE24240.

Evaluation of Sella Turcica and Maxilla Morphometry of Individuals With Cleft Lip and Palate on Lateral Cephalometric Radiographs

Objective: The objective of this study was to evaluate the dimensions and the morphology of the sella turcica, as well as maxillary cephalometric landmarks, in patients with and without clefts. Methods: Lateral cephalometric radiographs of 55 cleft patients and 55 non-cleft (control) patients were included in the study. The morphology of the sella turcica, including its shape, height, width, and diameter was evaluated. Additionally, maxillary cephalometric measurements, comprising four lengths and two angles, were assessed on the radiographs. The chi-squared test was employed to compare sella turcica shapes between the cleft and non-cleft groups. Independent samples t-tests were conducted to analyze dimensional parameters between groups and genders. Results: Significant relationship was found between groups with cleft and non-cleft for sella shapes (p=0.032). There was no statistical association for sella dimensions according to the cleft presence (p&gt;0.05). All maxillary cephalometric measurements were significantly greater in individuals of the non-cleft group compared to those in the cleft group (ANS-PNS, A-PNS, S-N-ANS , S-N-A, N-A) except R-PNS. Conclusion: Patients with clefts more frequently exhibited a flattened sella shape, whereas those without clefts tended to have a round sella shape. Maxillary cephalometric dimensions were lower in the individuals of cleft group.

Pseudocapsular resection to prevent recurrence in nonfunctioning pituitary neuroendocrine tumors: a retrospective, single-center study with more than 5 years of follow-up.

Pseudocapsular resection is a well-recognized, useful approach to achieve endocrinological remission in functioning pituitary neuroendocrine tumors (PitNETs). However, its advantage in nonfunctioning PitNETs (NF-PitNETs) has not been established. This study aimed to clarify the contribution of pseudocapsular resection to the prevention of NF-PitNET recurrence in long-term follow-up. This retrospective study included 132 patients who underwent total tumor removal and were followed for more than 5 years after surgery. The patients were categorized into those who underwent total pseudocapsular resection (n = 67) and those who did not (n = 65). The nonpseudocapsule (nonpseudocap) resection group included patients who underwent partial pseudocapsular resection and those in whom the pseudocapsule was not resected, did not exist, or could not be identified during surgery. The main outcome measures were the tumor recurrence rate and site of recurrence. In the nonpseudocap resection group, 2 patients (3.1%) had tumor recurrence in the cavernous sinus and 5 (7.7%) had tumor recurrence in the pituitary fossa. In the pseudocapsule (pseudocap) resection group, only 2 patients (3.0%) had tumor recurrence in the cavernous sinus and 0 patients had tumor recurrence in the pituitary fossa. Tumor recurrence in the pituitary fossa was more likely to occur in the nonpseudocap resection group than in the pseudocap resection group (p = 0.0267). Multivariate regression analysis revealed that pseudocapsular resection was a significant factor for reducing the tumor recurrence rate in the pituitary fossa (p = 0.0107). Pseudocapsular resection may reduce the rate of tumor recurrence and improve the management of NF-PitNETs in long-term follow-up.

Anatomical Features and Morphometric Characteristics of the Sphenoidal Sinus in MRI Studies.

Differential access to pathological sellar processes and adjacent regions is determined by the anatomic structures identified through diagnostic imaging. Both direct endonasal access (microscopic or endoscopic) and sublabial access utilize the sphenoid sinus (SS) as the primary surgical pathway. Critical factors include the pneumatization of the sinus, its intermediate septa, and the presence of a double wall, consisting of a connective tissue membrane along the dorsal wall of the SS. The present study aims to demonstrate the significance of the size and type of the SS based on MRI measurements. The type of SS, its pneumatization, and the proximity of adjacent brain structures are crucial for different surgical approaches to the SS and pituitary fossa. In neurosurgical practice, six main types of sinuses are recognized: sphenoid body type, lateral type, clival type, lesser wing type, anterior type, and combined type. Failure to consider these variations can lead to damage to the cavernous sinus, Meckel's cave, nerve structures in the middle cranial fossa, planum sphenoidale, suprasellar region, and vital brainstem structures located on the clivus. Randomly included MRI measurements were conducted on 112 patients from Pulmed University Hospital, Plovdiv, Bulgaria, categorized into two cohorts based on gender, with mean ages of 51 years for men and 47.8 years for women. The measurements, recorded in centimeters, were obtained using two imaging software programs, RadiAnt DICOM Viewer (Medixant, Poznan, Poland) and Weasis DICOM Viewer (Nicolas Roduit, https://github.com/nroduit/Weasis). No statistically significant differences were observed between the measurements produced by the two programs. Measurements of the SS were taken in two equal groups, using three different projections: axial, sagittal, and coronal. The results for height, width, and depth showed average sizes of 2.73-3.04 cm in axial projections, 1.70-2.64 cm in sagittal projections, and 2.86-3.03 cm in coronal projections. The minor differences between axial and coronal measurements of the same parameters (height and width) are statistically acceptable and attributed to the varying angles of the MRI scans. These measurements are crucial for planning surgical access to the sellar and parasellar regions, determining the necessary bony resection of the posterior wall of the SS, and preventing complications from excessive bony trepanation.

Craniofacial morphology in patients with impacted canine: a case control-study.

The objective of this study was to evaluate the risk of maxillary canine impaction through cephalometric evaluation. One hundred and eighty-two Caucasian patients (80 males and 102 females) with a mean age of 12.4±0.5 were retrospectively enrolled in the present study. Ninety patients with impacted canines were compared with ninety-two patients with physiologically erupted canines. The following cephalometric variables were analyzed: SNA, ANB, SN-GOME, GO-ME, SP-CL, SELLA TURCICA DEPHT, A-Pt LINE, B-Pt LINE, A-Pt LINE°, B-Pt LINE°, A1s-Pt, A1i-Pt, A1s-Pt°, A1i-PT°, A-SN, B-SN and SN-U1. When applicable, a paired sample t-test was performed to investigate the difference in means between the two sample groups, while the Mann-Whitney Test was used as a non-parametric test in the case of a non-normal distribution of data. Statistical significance was set at P<0.05. The group with impacted canines showed an increase in Go-Me distance, SNA angle and A1s-Pt angle compared with the control group. In addition, the same group showed a decrease in A-SN and SP-Cl distance compared with the control group. An increase in mandibular length (GO-ME) and SNA angle associated with a reduction in A-Sn distance and interclinoid distance (SP-Cl) were observed in patients with impacted canines.

Influence of cranium orientation on cervical sagittal alignment during radiographic examination: a radiographic analysis

BACKGROUND CONTEXTDuring the radiographic examination, the cranium orientation varies not only individually but also within the same subject, in different imaging sessions. Knowing how changes in the orientation of the cranium influences cervical sagittal alignment during the radiographic examination of the cervical spine can aid clinicians in the accurate evaluation for cervical sagittal alignment in clinical practice. PURPOSETo radiographically examine the influence of cranium orientation on cervical sagittal alignment during radiographic examination in an asymptomatic cohort. STUDY DESIGNA prospective radiographic study. PATIENT SAMPLEEighty asymptomatic volunteers (mean age, 40.4 years; 50.0% male) were enrolled. OUTCOME MEASURESCervical sagittal parameters including the regional slope (C1 slope, C2 slope, C5 slope, C7 slope, and T1 slope), Cobb angle (O–C1 angle, C1–C2 angle, C2–C5 angle, C5–C7 angle, and C7–T1 angle), and cranial/cervical offset (sella turcica tilt [ST tilt] and C2 tilt). METHODSIn all participants, standing lateral radiographs of the cervical spine were taken in three forward-gazing positions: anteverted-cranium (AC) position; neutral-cranium (NC) position; and retroverted-cranium (RC) position. Cervical sagittal parameters, including the regional slope, Cobb angle, and cranial/cervical offset, in these three positions were statistically compared. RESULTSThe C1 and C2 slopes were anteverted and retroverted in the AC and RC positions, respectively, compared to those in the NC position. The C5 slope, C7 slope, and T1 slope were constant among the three positions. In O–C2 and C2–C5, statistically significant differences in the regional Cobb angles were identified among the three positions; however, there were no significant differences in the C5–C7 or C7–T1 segments. Cranial and cervical offsets of ST tilt and C2 tilt increased and decreased when the cranium was anteverted and retroverted, respectively. CONCLUSIONSThe current study suggests that the adjustment of the cranium orientation when taking cervical spine radiographs is mainly controlled at the upper cervical spine of the O–C2 segment in an asymptomatic cohort. On radiograph, alignment in the upper cervical segment of O–C2 changes; accordingly, the middle cervical segment of C2–C5 can change during the adjustment of cranium orientation. However, alignment in the lower cervical segment of C5–C7 and the cervicothoracic junction of C7–T1 remains constant. Further, cranial/cervical offset increases and decreases when the cranium is anteverted and retroverted, respectively. Our results can help the accurate evaluation of cervical sagittal alignment on plain radiographs in clinical practice.

World premiere: transoral robot-assisted excision for nasopharyngeal ectopic pituitary adenoma.

Pituitary adenoma (PA), though rare, has seen increased incidence with widespread MRI use, enabling incidental diagnosis. Prevalence is approximately 1 case per 1000 in the general population. PAs are benign neoplasms, constituting 10 to 20% of intracranial tumours. Ectopic pituitary adenoma developed outside the sella turcica is exceptional. It may be hormonally active or not. These are called nonfunctional pituitary adenomas. Here is reported a case of a man in his eighties with a nasopharyngeal ectopic pituitary adenoma treated by robot-assisted excision using a combined route. CARE guidelines have been respected. A man in his eighties, asymptomatic, underwent an MRI for dizziness, revealing a nasopharyngeal mass. Despite being asymptomatic, nasofibroscopy revealed a reddish oval-shaped tissue mass attached to the roof of the nasopharynx. Biopsy identified a neuroendocrine tumor G1/G2. Imaging showed no local invasion or distant metastases. A multidisciplinary team decided on a robot-assisted surgical excision through the mouth, coupled with nasal endoscopy. The procedure achieved complete excision with clear margins and no adverse event has occurred. This unique case involved the successful transoral robot-assisted excision of a nasopharyngeal ectopic pituitary adenoma, highlighting an innovative surgical approach.

Molecular developments in parasellar tumors and potential therapeutic implications.

The parasellar region is the anatomical area around the sella turcica that represents a crucial crossroad for important adjacent structures. Several distinct tumors can primarily originate from this area, the most common being meningiomas, gliomas, embryonal cell tumors, germ cell tumors and craniopharyngiomas. In addition, a number of systemic and inflammatory disorders can also affect the parasellar region most commonly involving the pituitary. These lesions have different pathology characteristics and malignant potential according to the new WHO CNS5 2021 classification. Signs and symptoms may be non-specific and are mostly related to a mass effect on the surrounding anatomical structures and/or impairment of endocrine function whereas the vast majority lack a secretory component. The mutational signature analysis based on advances in molecular techniques, has recently enabled the identification of specific gene mutations or signalling pathway aberrations. These developments may serve as a powerful mean to delineate the pathophysiology of these lesions and serve as a diagnostic, prognostic and therapeutic tool, particularly for high-risk populations. Treatment options include surgery alone or in combination with radiotherapy, chemotherapy and disease-specific medical therapy in order to prevent recurrence or further tumor growth along with replacement of coexistent pituitary hormonal deficiencies. In this comprehensive review, we present current state-of-the-art developments in the histopathology and molecular biology of these lesions that may be utilized by a dedicated multidisciplinary team of relevant specialties for the diagnosis, monitoring and treatment of the parasellar lesions that often represent a diagnostic and therapeutic challenge.

Sella turcica and facial bones: Morphological integration in the human fetal cranium.

The cranial base plays a significant role in facial growth, and closer analyses of the morphological relationship between these two regions are needed to understand the morphogenesis of the face. Here, we aimed to study morphological integration between the sella turcica (ST) and facial bones during the fetal period using geometric morphometrics. Magnetic resonance images of 47 human fetuses in the Kyoto Collection, with crown-rump lengths of 29.8-225 mm, were included in this study. Anatomical homologous landmarks and semilandmarks were registered on the facial bones and the midsagittal contour of the ST, respectively. The shape variations in the craniofacial skeleton and the ST were statistically investigated by reducing dimensionality using principal component analysis (PCA). Subsequently, the morphological integration between the facial bones and ST was investigated using two-block partial least squares (2B-PLS) analysis. PCA showed that small specimens represented the concave facial profile, including the mandibular protrusion and maxillary retrusion. The 2B-PLS showed a strong integration (RV coefficient = 0.523, r = .79, p < .01) between the facial bones and ST. The curvature of the anterior wall of the ST was highly associated with immature facial morphology characterized by a concave profile. The strong integration between the two regions suggested that the anterior ST may be associated with facial morphology. This result quantitatively confirms previous studies reporting ST deformities in facial anomalies and induces further research using postnatal subjects.

Transsphenoidal Approach for Pituitary Macroadenoma: Complications

Transsphenoidal surgery (TSS) is a popular method for resecting pituitary tumors, but it has been associated with severe consequences such as perioperative medical issues, endocrine problems, and surgical complications. The pituitary gland, a bilobed endocrine organ, contains eight hormones and is surrounded by the sella turcica, tuberculum sellae, dorsum sellae, and cavernous sinus dura. The gland's structure is complex, with the optic chiasm and sphenoid sinus being significant structures. The sphenoid sinus, which grows with age and has variable septal and cavitary architecture, can make the transsphenoidal approach more difficult to perform in cases of bleeding, vision loss, or cranial nerve palsy. Understanding the anatomy of the sphenoid sinus is crucial for a safe sellar approach and tumor removal. The operative microscope introduced in the 1960s has further improved surgical outcomes with low morbidity and mortality rates. Pituitary adenomas are extra-arachnoidal tumors that develop outside the boundaries of the cerebrospinal fluid (CSF). They can cause iatrogenic leaks if the arachnoid membrane is ruptured and a cerebrospinal fluid fistula is introduced. Delayed postoperative epistaxis can result from the sphenopalatine artery and the intracavernous internal carotid artery (ICA). Loss of vision can result from physical injuries to the optic nerves or chiasm, which can occur at multiple stages of the operation. Other causes include cerebral vasospasm, traction injury, empty sella syndrome with chiasm prolapse, ophthalmoplegia, and internal injuries to the carotid artery. Injuries to the sphenoid sinus, including proximity to essential tissues, thin or absent bone, and loss of bone, increase the risk of iatrogenic injury. Packing is the initial therapy, and postoperative angiography should be performed afterward. Embolization is considered in situations where packing is inadequate or when there is development to pseudo-aneurysms or carotid cavernous fistulae. Chronic Insipidus Diabetes (DI) is a common disturbance in patients following transsphenoidal surgery (TSS), causing water and electrolyte problems. DI can manifest in various clinical patterns, including transitory, permanent, and triphasic phenotypes. Postoperative syndrome of antidiuretic hormone secretion (SIADH) is also a risk factor, with hyponatremia often delayed and symptomatic. Improved or newly developed hypopituitarism is a risk, with the hypothalamic-pituitary-adrenal (HPA) axis being the most susceptible. Transcranial procedures with HPA or other axis deficits may cause damage to normal residual glands, especially in large tumors. Transsphenoidal techniques can mitigate the risk of dissecting an attenuated gland, but understanding pituitary physiology and sellar anatomy is crucial for improving the procedure and encouraging innovation. Transcranial procedures have a low death rate and risk of significant impairment, but understanding the underlying medical, endocrine, and surgical consequences is essential for successful PA excision.

How I do it: Endoscopic endonasal resection of the medial wall of the cavernous sinus.

Resection of the medial wall of the cavernous sinus (MWCSR) is a growing surgical maneuver for the radical removal of pituitary adenomas. We present a simple modification of the technique following the two dural layers of the floor of the sella turcica, allowing for early identification of the medial wall and simplifying dissection. We support this technique with an anatomical analysis on cadaveric specimens and clarifying dissection images. Recognition and dissection of the dural unfolding of the floor of the sella turcica are "key points" that lower the risk and facilitate the MWCSR.