Primary Empty Sella

Primary empty sella (PES) syndrome is a misnomer as it is not a syndrome but a radiological finding with possible endocrine abnormalities. No specific headache type has been shown to be caused by PES. Endocrine screening may be considered for asymptomatic persons with PES.     

Hypoxia and hypercarbia of chronic lung disease: minimal effects on anterior pituitary function

Previous studies have suggested that the hypoxia and/or hypercapnia associated with chronic lung diseases may lead to pituitary and gonadal dysfunction, with destruction of the sella turcica. It is unclear, however, whether these abnormalities were due to lung disease or to confounding factors. We studied the relationships between hormonal levels (triiodothyronine, thyroxine, T3 resin uptake, thyrotropin, prolactin, cortisol, and testosterone) and PaO2, PaCO2, pH, and alveolar-arterial gradient in 25 patients with chronic lung disease. These patients were highly homogeneous for diagnosis, age, sex, ambulatory status, lack of other illnesses, and minimal use of medications unrelated to lung disease, but did have various degrees of hypoxia and hypercarbia at the time of study. We found no relationship between hormonal levels and lung function, or evidence of major pituitary involvement on lateral roentgenograms of the skull, CT of the sella turcica, or stimulation of the pituitary. An inverse correlation did occur between serum levels of thyroxine and the daily dose of oral prednisone. We conclude that most of the endocrine dysfunction ascribed to chronic lung diseases is probably due to factors other than hypoxia or hypercarbia.     

Rare empty sella syndrome found after postoperative hypotension and respiratory failure:A case report

BACKGROUND Empty sella syndrome is a condition in which the pituitary gland shrinks or flattens. Patients with empty sella syndrome often present with headache,hypertension, obesity, visual disturbances, cerebrospinal fluid(CSF) rhinorrhoea,or endocrine dysfunction. Herein, we report a rare case of empty sella syndrome discovered after the patient experienced postoperative hypotension and respiratory failure.CASE SUMMARY A 60-year-old man was admitted for further workup of left shoulder pain. He was assessed by the orthopaedics team and booked for internal fixation of the left clavicle. General anaesthesia with a nerve block was administered. His blood pressure continued to decrease post-operation. Endocrine tests were performed,with the results supporting a diagnosis of hypopituitarism with hypocortisolism and hypothyroidism. Brain magnetic resonance imaging demonstrated that the sella was enlarged and filled with CSF, confirming a diagnosis of empty sella syndrome. The patient was started on endocrine replacement therapy. The patient regained consciousness and spontaneous breath finally.CONCLUSION This case highlights the importance of considering pituitary hormone insufficiency in the context of respiratory and hemodynamic failure during the perioperative period.     

Empty Sella Headache

SYNOPSIS
Headache was studied in a series of empty sella cases and the findings were compared with previous observations. Headache appeared to be very frequently associated with empty sella and its clinical features appeared distinguishable from migraine and tension headache, but very similar to pituitary chromophobe adenoma headache. Such an association seems to be in most cases pathogenetically significant and empty sella headache should therefore be included among the "secondary" headaches to be considered in the current diagnosis.     

Headache associated with pituitary tumors

The objective of this study is to analyze the presence of headache in pituitary tumors and their characteristics, the relationship between pituitary tumor size, biological type, local extension and intrasellar pressure (ISP). This is a prospective study, of 64 consecutive patients presenting with primary pituitary masses at Neuroendocrinological Department of General Hospital of Fortaleza from October 2005 to December 2006. We analyzed sex, age, headache (laterality, site, severity, quality, frequency, duration, associated symptoms, time of onset, trigger, alleviating factors and familial history) and tumor characteristics (type, size, quiasmatic compression, cavernous sinus invasion, sella turcica destruction, cystic or solid mass and ISP). We observed a statistic significant factor between pituitary tumor and tumor size, optic compression, sellar destruction, cavernous sinus invasion and ISP. Biochemical-neuroendocrine factors, mainly in prolactinomas, seem to be an important factor in the determination of headache. The presence of headache in pituitary tumor is related to a combination of factors, including ISP, tumor extension, relationship with the sellar structures, patient predisposition, familial history, and functional disturbance within the hypothalamo-pituitary axis.     

The empty sella.

OBJECTIVE: To discuss the diagnostic imaging findings of an empty sella in a chiropractic patient with emphasis on magnetic resonance imaging (MRI) of normal and abnormal pituitary appearances. CLINICAL FEATURES: A 44-year-old woman started having headache, dizziness, nausea, vomiting, and diarrhea after an argument with her boyfriend. She had been treated for acute torticollis for three weeks when the new symptoms began. Consultation with an internist led to an MRI examination of the cerebellopontine angles to exclude an acoustic neuroma. The MRI demonstrated an enlarged empty sella. There was no history of pituitary tumor or other sellar disease. INTERVENTION AND OUTCOME: There was complete remission of the symptoms after 1 additional dizzy spell that occurred 3 days after the initial symptom. No intervention was performed, but the stress levels in her life had been reduced. CONCLUSION: An enlarged empty sella can be present without symptoms and can represent an incidental finding on radiography and MRI. However, an enlarged sella seen on lateral cervical spine radiographs should prompt further evaluation to rule out pituitary disease. The normal pituitary has a varied appearance and signal intensity on MRI depending on the patient's age and pregnancy status.     

How Well Do Headache Patients Remember? A Comparison of Self-Report Measures of Headache Frequency and Severity in Patients with Migraine

Objective.— To compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in an interval questionnaire vs a daily diary.
Background.— Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment. As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire.
Methods.— Headache frequency and average severity (0 to 3-point scale) were reported in an interval questionnaire by 209 patients who had also maintained a daily diary over the same 4-week period.
Results.— Headache frequency over the previous 4 weeks as reported in interval questionnaires (14.7) was not different from that documented in diaries (15.1), P  = .056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1.84) was worse than that documented in the diaries (1.63), P  < .001.
Conclusions.— In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable.     

Endocrinological abnormalities in myotonic dystrophy: consecutive studies of eight tolerance tests in 26 patients

We studied endocrine functions of the hypothalamus, pituitary, thyroid, gonad, adrenal and pancreas in 26 patients with myotonic dystrophy. The following findings were obtained: (1) Hyporesponsivenesses of HGH to insulin, arginine and L-dopa test were observed in 25%, 45% and 54.5% of patients, respectively. To the administration of sulpiride and TRH, hypo- or hyperresponses of plasma PRL were observed in 4 or 2 patients, respectively. (2) Depressed plasma levels of testosterone were observed in 4 patients and those of estradiol were observed in 3 patients. Among these 7 patients, five were hypergonadotropic and the remaining two were hypogonadotropic. From the data of plasma cortisol and urinary 17-OHCS, the adrenal functions in patients with myotonic dystrophy were considered to be normal. The renin-angiotensin-aldosterone systems in these patients were considered to be grossly normal. (3) Basal levels of T3, T4 and free T4 were within the normal ranges, but 6 of 19 patients showed low levels of 131I-uptake and 11 of 24 patients showed reduced BMR values. (4) The basal level of plasma insulin was elevated in 5 patients. Insulin responses to oral glucose were exaggerated and delayed in 21 of 26 patients. From these results and the statistical evaluation of each laboratory and clinical data, we concluded that 1) the degrees of disturbances of endocrine functions are at random in each patient. 2) The measures of intellectual function obtained by WAIS were directly correlated with basal levels of TSH, but inversely with basal levels of somatostatin. No specific correlation was found between endocrinological disturbances and neurological severities. 3) Impairment of some endocrine functions, such as the gonadal, thyroid and somatotroph functions, was closely correlated with age and the duration of disease.     

Ergotamine abuse: Results of ergotamine discontinuation, with special reference to the plasma concentrations

Twenty-three patients suffering from continuous headache linked with habitual daily use of ergotamine tartrate were studied. Their headaches were classified clinically, and possible side effects of ergotamine medication, plasma levels of ergotamine, and occurrence of withdrawal symptoms after discontinuation of drug abuse were recorded. Seventeen of the patients were clinically diagnosed as suffering from "ergotamine headache", and seven of them complained of coldness in the extremities. Plasma ergotamine levels were measured by using a radioimmunoassay. In almost half of the patients the 1 h plasma levels after the daily dose were below the detection limit of the procedure (0.12 ng/ml). The duration and severity of the withdrawal symptoms did not correlate with the doses and plasma levels of ergotamine. In only 4 of the 21 patients who were followed up for 3 to 6 months did headache symptoms not improve after ergotamine withdrawal. The results indicate that even small (0.5–1.0 mg/day) doses of ergotamine tartrate taken regularly may cause continuous headache symptoms and withdrawal symptoms after discontinuation.     

Medication Overuse Headache in School‐Aged Children: More Common Than Expected?

Objective.— To investigate the prevalence of medication overuse headache (MOH) in a group of children and adolescents seen for headache in a third‐level center in Italy. Background.— Epidemiological studies indicate a prevalence of MOH in children and adolescents between 0.3 and 0.5%; no data are available for the Italian population. Methods.— We studied a group of first‐seen children and adolescents (118 patients, 43.2% male and 56.8% female, mean age: 11.9 years). A detailed history was taken, using criteria defined by Olesen et al to assess the presence of MOH. Statistical correlations between demographic and diagnostic variables were assessed. Results.— Eleven (9.3%) of our patients presented MOH; in the group with chronic daily headache, the prevalence raised to 20.8%. At follow up, after introduction of a more rationale treatment, most patients improved, but 2 of them reported a worsening of their headache. Conclusions.— We believe that a strong warning regarding medication overuse in headache therapy is essential for pediatricians and neuropsychiatrists.     

Classification of chronic daily headache by International Headache Society criteria: limits and new proposals

We conducted a retrospective study of 150 patients with chronic daily headache (CDH) to determine how to categorize their headache according to the classification of the International Headache Society (IHS). All patients were first evaluated at Parma and Pavia Headache Centres (from January 1992 to March 1993) and had had headache for at least 15 days a month during the previous 6 months. Four patients were thereafter excluded due to poor reliability. The 146 patients who met our CDH criteria (92 with and 54 without clear-cut migraine attacks) could be classified into four groups: (i) chronic tension-type headache (CTTH)-27 patients; (ii) coexisting migraine plus CTTH-65 patients; (iii) unclassifiable daily headache-27 patients; and (iv) migraine and an unclassifiable interval headache-27 patients. Seventy-two percent of patients with CDH had migraine as the initial form of their headache. We therefore propose to revise the IHS classification for migraine, taking into account its evolution, and add two subcategories, migraine with interparoxysmal headache and chronic migraine.     

Headache associated with pituitary adenomas

The objectives of this study were to analyze the characteristics of headache in patients with pituitary adenoma and to investigate the mechanisms involved. Fifty-one patients (27 females and 24 males) with pituitary adenoma were examined. Nineteen (37.3%) of these patients (13 females and 6 males) had headache preoperatively. Most commonly, the headache was generalized (42.1%); overall headache was more frequent in the anterior half of the head (84.2%). Seventeen (89.5%) patients had bilateral headache. Headache was usually described as head heaviness (57.9%) and continuous (57.9%). Pulsating headache and dull pain were only reported by the female patients and were mostly intermittent. The mean age of patients with headache was younger than that of those without headache. Headache was more prevalent in patients with a prolactin-secreting adenoma (57.1%). There were no correlations between visual disturbances, hypopituitarism, tumor size, or cavernous sinus invasion and headache. Hemorrhagic pituitary adenoma in 4 (57.1%) of 7 patients did not always contribute to headache. The headache was improved after surgery in 14 (73.6%) of the 19 patients. In the male patients who survived postoperatively (5 of 6), headache was improved.     

Prevalence and Clinical Features of Chronic Daily Headache in a Headache Clinic

Although chronic daily headache is regarded as a syndrome encountered in headache clinics, clinical characteristics have only rarely been studied and the condition has not been documented in Thailand. To investigate the prevalence as well as clinical features of chronic daily headache in Thai patients, 220 patients visiting Chulalongkorn Headache Clinic were examined. Sixty cases (27.3%) were diagnosed as suffering from chronic daily headache (male to female ratio, 1:5.7).
The average age of these patients was 32.7 ± 9.6 years. Based on the International Headache Society (IHS) criteria, 30% of patients with chronic daily headache could be diagnosed as suffering from migraine end 36.7% from chronic tension-type headache, whereas the remainder had combined features of both headache types and were not classifiable. Diffuse steady pain was the most common headache type reported (65%), however, associated features characteristic of migraine were often noted. These included photophobia (70%), phonophobia (56.7%) and nausea (43%). Thirty-four cases (56.7%) reported that their headache could be aggravated by stress. Daily use of analgesics was reported in 58.3% of cases. We concluded that chronic daily headache is a common problem. Although the mechanism has not been fully clarified, the prevalence of associated psychological factors and analgesic overuse imply their involvement in the pathogenesis of this condition. The criteria of the IHS are not entirely suitable for diagnosis and classification of this disorder, and modification of this classification system is needed.     

Headache Associated With Pituitary Adenomas

The objectives of this study were to analyze the characteristics of headache in patients with pituitary adenoma and to investigate the mechanisms involved.
Fifty-one patients (27 females and 24 males) with pituitary adenoma were examined. Nineteen (37.3%) of these patients (13 females and 6 males) had headache preoperatively. Most commonly, the headache was generalized (42.1%); overall headache was more frequent in the anterior half of the head (84.2%). Seventeen (89.5%) patients had bilateral headache. Headache was usually described as head heaviness (57.9%) and continuous (57.9%). Pulsating headache and dull pain were only reported by the female patients and were mostly intermittent. The mean age of patients with headache was younger than that of those without headache. Headache was more prevalent in patients with a prolactin-secreting adenoma (57.1%). There were no correlations between visual disturbances, hypopituitarism, tumor size, or cavernous sinus invasion and headache. Hemorrhagic pituitary adenoma in 4 (57.1%) of 7 patients did not always contribute to headache. The headache was improved after surgery in 14 (73.6%) of the 19 patients. In the male patients who survived postoperatively (5 of 6), headache was improved.     

原发性高颅压垂体和蝶鞍形态改变机制及MR研究

目的 对原发性高颅压病人的垂体和蝶鞍的形态进行研究。方法 本组包括32例临床诊断为原发性高颅压病人。对垂体和蝶鞍形态进行分级评价。结果 绝大部分原发性高颅压病人（90.6%)出现垂体形态的改变。本组病例中病史短者,垂体和蝶鞍出现形态变化的例数和变化的程度都较病史长者稍轻,但垂体形态的变化（n=29)多于蝶鞍的变化（n=18)。结论 原发性高颅压引起垂体和蝶鞍形态改变,可能与长期高颅压作用于鞍区有关。     

Hypopituitarism

The pituitary regulates the body's endocrine system, including the thyroid gland, adrenal cortex, ovaries and testes, through the release of numerous hormones. Pituitary function, in turn, is regulated through complex feedback loops involving the hypothalamus and the target endocrine glands. Hypopituitarism may result from multiple causes, including primary and metastatic cancer, ischemic and granulomatous disease, infection, developmental abnormalities and trauma, which may affect the gland itself (primary hypopituitarism) or the hypothalamus (secondary hypopituitarism). Depending on the anatomic lesion, patients with hypopituitarism may present with signs or symptoms of multiple endocrine abnormalities, such as hypothyroidism, adrenal insufficiency, diabetes insipidus, hypoglycemia, sexual dysfunction and growth retardation. A thorough clinical history, detailed examination, laboratory evaluation of endocrine function and radiographic views of the pituitary and sella turcica can suggest the diagnosis and etiology. Treatment, usually lifelong, may include hormone replacement and medical or surgical correction of the underlying disease.     

Preventive medication adherence in african american and caucasian headache patients

(Headache 2011;51:520‐532) Study Objectives.— To examine race‐related differences in adherence to preventive medication agents in headache patients and identify factors predictive of medication adherence in Caucasian and African American headache patients. Methods.— Using a longitudinal naturalistic study design, data from 77 Caucasian and 32 African American headache patients were collected through (1) 30‐day daily diaries that assessed medication adherence, headache frequency, and headache episode severity; (2) self‐administered surveys that assessed headache management self‐efficacy; and (3) telephone‐administered psychiatric interviews that yielded psychiatric diagnoses. Using daily diary adherence data, patients' adherence to preventive agents was dichotomized as “Inconsistent” (ie, adhered fewer than 80% of days) or “Consistent” (ie, adhered ≥80% of days during the past month). Results.— The proportion of adherent African American patients (69%) did not differ significantly from the proportion of adherent Caucasian patients (82%). Exploratory univariate logistic regression analyses found that preventive medication adherence levels of 80% or less were associated with being diagnosed with major depressive disorder and lower levels of headache management self‐efficacy. Conclusions.— Future research should test if interventions that reduce depressive symptoms and increase patients' levels of headache management self‐efficacy can produce concomitant increases in adherence to preventive headache agents.     

Chronic headache and pituitary tumors

Pituitary tumors come to clinical attention due to endocrine dysfunction, distortion of local structures surrounding the pituitary fossa, or as an incidental finding during neuroimaging for headache. Explanations for pituitary tumor-associated headache include stretching of the dura mater and invasion of pain-producing structures within the cavernous sinus. However, small functional pituitary lesions may present with severe headache without cavernous sinus invasion or suprasellar extension. Prolactinomas and growth hormone-secreting tumors have a high prevalence of rare headache phenotypes with or without autonomic features, suggesting that biochemical abnormalities within the hypothalamo-pituitary axis may play a role in headache. Somatostatin analogues may be highly effective at aborting headache associated with functionally active pituitary lesions, particularly in the case of acromegaly. A proposed mechanism for this is inhibition of nociceptive peptides. This article summarizes the clinical features, pathophysiology, and potential treatment approaches to pituitary tumor-associated headache.     

New-onset cluster headache in middle-age and elderly women

Cluster headache is usually considered to affect young men. We hereby report on new-onset cluster headache in middle-aged and elderly women. We performed a retrospective chart review of female patients diagnosed with cluster headache (IHS criteria), and studied the charts of women in whom the headache started after the age of 50 years. Out of 168 patients (26 women, 15%) diagnosed with cluster headache, the headache started after the age of 50 years in seven women, of whom three reported past tension-type or migraine headaches. The mean age at the beginning of the headache was 61 +/- 8 years (range 52--72 years). In all cases, the pain was severe, strictly unilateral, and accompanied by at least one autonomic symptom. The average duration of the pain was 70 min (range 20 min--3 h), recurring daily for an average period of 7 weeks (range 1--16 weeks). Five patients had 1--2 pain attacks each day, while the other two experienced up to eight episodes of pain in 1 day. In two patients the periodicity of the pain was currently undetermined. In the remainder, the headache periods recurred every 1--4 years. Cluster headache is commonly considered to be a young-male disorder, but middle-aged and elderly women may also be affected. The characteristics of the pain and its manner of occurrence were similar in our cases to those reported in the young-male population.     

Preliminary comparison of the endoscopic transnasal vs the sublabial transseptal approach for clinically nonfunctioning pituitary macroadenomas.

OBJECTIVE: To assess the advantages and disadvantages of an endoscopic transnasal approach to pituitary surgery for a select group of clinically nonfunctioning macroadenomas and to compare results of this approach with the sublabial transseptal approach at a single institution. PATIENTS AND METHODS: We retrospectively reviewed the records of 26 patients with clinically nonfunctioning pituitary macroadenomas approached endoscopically and 44 matched control patients with the same tumors approached sublabially between January 1, 1995, and October 31, 1997. RESULTS: At baseline, the groups were not significantly different for age, sex distribution, number of comorbid conditions, visual field defects, degree of anterior pituitary insufficiency, or preoperative assessment of tumor volume or invasiveness. Mean (SD) operative times were significantly reduced in the endoscopic group vs the sublabial group: 2.7 (0.7) hours vs 3.4 (0.9) hours (P < .001). Postoperative assessment of surgical resection and postoperative alterations of anterior pituitary function or visual fields were not significantly different between groups, and complication rates were similar in both groups. CONCLUSION: This endoscopic transnasal approach to pituitary resection results in significantly shorter operative time without compromising the extent of tumor resection. The distinct disadvantage of this approach is an off-center view of the sella and a diminished working channel to the sella turcica. For these reasons, the endoscopic approach or its variation is an alternative to the sublabial approach but should be considered only by experienced pituitary neurosurgeons.