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Introduction Empty sella in MRI is an important finding associated with idiopathic intracranial hypertension (IIH). This study assesses the sensitivity and reproducibility of several morphological measures of the sella and pituitary gland to indentify the measure that best differentiates IIH from controls. Additionally, the study assesses reversal in gland compression following treatment. Methods Sagittal 3D-T1W sequence with 1 mm isotropic resolution was obtained from ten newly diagnosed IIH patients and 11 matched healthy controls. Follow-up MRI scans were obtained from eight patients at 1-week post-lumbar puncture and acetazolamide treatment. 1D and 2D measures of absolute and normalized heights and cross-sectional areas of the gland and sella were obtained to identify the measure that best differentiates IIH patients and controls. Results Overall area-based measurements had higher sensitivity than length with p  < 0.0001 for sella area compared with p  = 0.004 for normalized gland height. The gland cross-sectional areas were similar in both cohorts ( p  = 0.557), while the sella area was significantly larger in IIH, 200 ± 24 versus 124 ± 25 mm 2 , with the highest sensitivity and specificity, 100 % and 90.9 %, respectively. Absolute gland area was the most sensitive measure for assessing post treatment changes, with 100 % sensitivity and 50 % specificity. Average post-treatment gland area was 18 % larger ( p  = 0.016). Yet, all eight patients remained within the empty sella range based on a normalized gland area threshold of 0.41. Conclusions Sellar area is larger in IIH, and it demonstrated highest sensitivity for differentiating IIH from control subjects, while absolute gland area was more sensitive for detecting post treatment changes.

Background It is difficult for neurosurgeons to perceive the complex three-dimensional anatomical relationships in the sellar region. Methods To investigate the value of using a virtual reality system for planning resection of sellar region tumors. The study included 60 patients with sellar tumors. All patients underwent computed tomography angiography, MRI-T1W1, and contrast enhanced MRI-T1W1 image sequence scanning. The CT and MRI scanning data were collected and then imported into a Dextroscope imaging workstation, a virtual reality system that allows structures to be viewed stereoscopically. During preoperative assessment, typical images for each patient were chosen and printed out for use by the surgeons as references during surgery. Results All sellar tumor models clearly displayed bone, the internal carotid artery, circle of Willis and its branches, the optic nerve and chiasm, ventricular system, tumor, brain, soft tissue and adjacent structures. Depending on the location of the tumors, we simulated the transmononasal sphenoid sinus approach, transpterional approach, and other approaches. Eleven surgeons who used virtual reality models completed a survey questionnaire. Nine of the participants said that the virtual reality images were superior to other images but that other images needed to be used in combination with the virtual reality images. Conclusions The three-dimensional virtual reality models were helpful for individualized planning of surgery in the sellar region. Virtual reality appears to be promising as a valuable tool for sellar region surgery in the future.

Background There are controversial opinions about the effect of erupted second molars on distalization of the first molars. Most of the distalizing devices are anchored on the first molars, without including second molars; so, differences between sequentially distalize maxillary molars (second molar followed by the first molar) or distalize second and first molars together are not clear. The aim of the study was to compare sequential versus simultaneous molar distalization therapy with erupted second molar using two different modified Pendulum appliances followed by fixed appliances. Methods The treatment sample consisted of 35 class II malocclusion subjects, divided in two groups: group 1 consisted of 24 patients (13 males and 11 females) with a mean pre-treatment age of 12.9 years, treated with the Segmented Pendulum (SP) and fixed appliances; group 2 consisted of 11 patients (6 males and 5 females) with a mean pre-treatment age of 13.2 years, treated with the Quad Pendulum (QP) and fixed appliances. Lateral cephalograms were obtained before treatment (T1), at the end of distalization (T2), and at the end of orthodontic fixed appliance therapy (T3). A Student t test was used to identify significant between-group differences between T1 to T2, T2 to T3, and T1 to T3. Results QP and SP were equally effective in distalizing maxillary molars (3.5 and 4 mm, respectively) between T1 and T2; however, the maxillary first molar showed less distal tipping (4.6° vs. 9.6°) and more extrusion (1.1 vs. 0.2 mm) in the QP group than in the SP group, as well as the vertical facial dimension, which increased more in the QP group (1.2°) than in the SP group (0.7°). At T3, the QP group maintained greater increase in lower anterior facial height and molar extrusion and decrease in overbite than the SP group. Conclusion Quad Pendulum seems to have greater increase in vertical dimension and molar extrusion than the Segmented Pendulum.

Investigate the impact of diaphragm sellae competence on surgical outcomes and risk factors for postoperative hypothalamic injury (HI) in patients undergoing endoscopic transsphenoidal surgery (ETS) for infradiaphragmatic craniopharyngiomas (ICs). A retrospective analysis of 54 consecutive patients (2016–2023) with ICs treated by ETS was conducted. All tumors originated from the sellar region inferior to the diaphragm sellae and were classified into two subtypes in terms of diaphragm sellae competence: IC with competent diaphragm sellae (IC-CDS) and IC with incompetent diaphragm sellae (IC-IDS). Clinical features, intraoperative findings, and follow-up data were compared between subtypes. Postoperative HI was assessed using an magnetic resonance imaging-based scoring system. Fifty-four patients (29 males, 25 females) were included in this study, with 12 (22.2%) under 18 years old. Overall, 35 cases were IC-CDS, while 19 were IC-IDS. Compared with IC-CDS, patients with IC-IDS tended to have hormone hypofunction before surgery ( p  = 0.03). Tumor volume in IC-IDS group (9.0 ± 8.6 cm 3 ) was also higher than that in IC-CDS group (3.3 ± 3.4 cm 3 , p  = 0.011). Thirty-seven patients underwent standard endoscopic transsphenoidal approach (SEA) and 17 underwent an extended endoscopic transsphenoidal approach (EEA). Gross total resection (GTR) was achieved in 50 cases (92.6%). Postoperative CSF leak was observed in four patients (7.4%). Permanent diabetes insipidus (DI) occurred in 13 patients (27.7%), six in IC-CDS and seven in IC-IDS. Postoperative HI occurred in 38.9% of patients. Univariate analysis revealed that large tumor size ( p  = 0.014), prior hypopituitarism( p  = 0.048) and IC-IDS ( p  < 0.001) were significantly associated with postoperative HI. Multivariate analysis revealed that IC- IDS was the sole predictor of postoperative HI. To our knowledge, this is the largest case series in the literature to describe IC resected by endoscopic surgery in a single institution. Classification based on diaphragm sellae competence highlights distinct clinical features and surgical outcomes between IC-CDS and IC-IDS subtypes. Notably, IC-IDS is an independent risk factor for postoperative HI. Preoperative identification of subtype can guide surgical strategy and potentially minimize complications.

Purpose Langerhans cell histiocytosis (LCH) is a rare condition arising from the monoclonal expansion of myeloid precursor cells, which results in granulomatous lesions that characteristically express CD1a/CD207. We report a case of LCH in a 3-year-old male involving the sphenoid bone with extension into the sellar/suprasellar region. Case report A 3-year-old male presented with progressively worsening headaches and associated night sweats, neck stiffness, and fatigue over the previous 4 weeks. Magnetic resonance imaging (MRI) revealed a 2.4-cm lytic lesion within the basisphenoid, exerting mass effect upon the pituitary gland. A biopsy was performed to determine the etiology of the lesion. Postoperatively, the patient developed an intralesional hematoma with visual complications requiring emergent surgical resection via endoscopic endonasal approach. Final pathology confirmed LCH. The patient had improvement in his vision long term. Conclusions LCH extending into the sella is a rare but important diagnosis to consider in pediatric patients presenting with lesions in this region. We presented a case of a pediatric patient presenting with LCH of the sphenoid bone extending into the sella, with subsequent apoplexy and vision loss. Review of the literature showed varying treatment options for these patients, including purely surgical and non-surgical treatments. Early intervention may be necessary to avoid potentially devastating neurologic sequelae.

IgG4-related disease is a clinically significant immune-mediated condition that can involve multiple organs. In the central nervous system, IgG4-related hypertrophic pachymeningitis is characterized by dural thickening, and the resulting mass effect may lead to various neurological deficits and characteristic imaging findings. A 54-year-old Japanese man presented with a 6-month history of slowly progressive right-sided visual impairment and visual field loss. Neurological examination revealed no abnormalities other than reduced visual acuity and visual field defects. Cranial magnetic resonance imaging revealed marked dural thickening extensively involving the bilateral frontotemporal regions, widespread frontal white matter lesions, and transdiaphragmatic herniation of the rectus gyrus into the sella turcica. The serum IgG4 level was elevated (429 mg/dL), and a dural biopsy revealed inflammatory cell infiltration with IgG4-positive plasma cells, leading to a diagnosis of IgG4-related hypertrophic pachymeningitis. Systemic evaluation, including laboratory screening and trunk computed tomography, revealed no other organ involvement apart from cervical and hilar lymphadenopathy. The patient responded well to steroid treatment (intravenous methylprednisolone followed by tapered oral prednisolone), with gradual improvement of the dural thickening, white matter lesions, rectus gyrus herniation, and visual field defects over 3 months. The serum IgG4 level decreased to 70.3 mg/dL. This case was characterized by pronounced dural thickening, widespread white matter lesions, and unprecedented rectus gyrus herniation into the sella turcica, a combination of features not previously reported. Neurologists should consider IgG4-related disease in the differential diagnosis of hypertrophic pachymeningitis accompanied by white matter lesions because early recognition and treatment may prevent irreversible neurological damage.

Purpose Intrasellar arachnoid cysts are extremely rare, and their differentiation from other cystic lesions can be challenging because of their similar imaging characteristics. Methods This study aimed to describe the imaging characteristics observed in five patients and correlate them with developmental and growth mechanisms. Results These cysts are characterized by the lack of contrast enhancement in their walls and posterior displacement of the pituitary gland. As a result, no enhancing tissue is present at the anterior portion of the sella where it interfaces with the sphenoid sinus. Conclusion We believe that this sign will lead to more accurate diagnosis and improve surgical planning.

Introduction Tumorous growths in the sellar region pose significant clinical challenges due to their proximity to critical visual structures such as the optic chiasm and optic nerves. Given their proximity to the optic system, these tumors are often diagnosed due to a progressive decrease in visual acuity. Thus, surgical intervention is crucial to prevent irreversible damage, as timely decompression can halt the progression of edema and subsequent optic atrophy. Although Quantitative Pupillometry (QP) has been employed in various clinical settings, its application in patients with sellar region neoplasms remains unexplored. This study aims to evaluate the utility of QP to enhance treatment approaches in patients undergoing surgical resection of these tumors. Methods Pupillometry assessments were conducted prospectively using the automated NPi 200® Pupillometer on 45 patients who underwent surgical resection of tumors in the sellar region at our institution. The Neurological Pupil Index (NPi) was measured pre- and post-operatively, with a focus on correlations with visual acuity and tumor volume. Concurrently, MRI findings were analyzed to assess optic chiasm compression. Results Of the patients, 73.3% were diagnosed with pituitary tumors, 22.2% with tuberculum sellae meningiomas, and 4.4% with craniopharyngiomas. 66.7% of patients presented with decreased visual acuity, and 42.2% demonstrated paresis of the third cranial nerve (CN III). Compression of the optic chiasm was noted in 55.6% of cases. Patients with visual disturbances and CN III paresis exhibited significantly reduced NPi scores compared to unaffected individuals. In patients with pituitary adenomas, pathological NPIs were observed exclusively in cases of optic chiasm compression; compression of cranial nerve III (CN III) did not significantly affect the NPIs. Conversely, in patients with tuberculum sellae meningiomas, pathological NPIs were associated specifically with CN III compression, while optic chiasm compression tended to show a difference, however the results are not significant. Postoperatively, NPi values normalized among those who had presented with decreased visual acuity. Conclusions This study contributes to the field of skull base surgery by evaluating the utility of QP as a diagnostic tool for neurological assessment in patients with sellar region tumors. The findings suggest that QP may help in assessing the extent of tumor-related compression on the optic system. It particularly points to differences in the effects of optic chiasm and CN III compression, with observed variations in NPI scores corresponding to the type of compression in specific tumors, such as pituitary adenomas and tuberculum sellae meningiomas. By providing rapid and non-invasive assessments, QP supports enhanced correlation with clinical and radiological evaluations, potentially improving targeted interventions for these complex conditions.

Abstract Context Although most sellar lesions are related to pituitary adenomas, the region gives rise to a variety of neoplasms that can be associated with substantial morbidity and/or mortality. Design Information from reviews and guidelines of relevant societies dealing with such neoplasms, as well as articles that have provided new developments that made important contributions to their pathogenesis and treatment up to 2018, were obtained: public indexes such as PubMed/MEDLINE were used with the relevant search items. Results Sellar neoplasms have a worse outcome than pituitary adenomas that is related not only to their natural history but also to side effects of therapies and evolving endocrine and/or hypothalamic deficiencies. Recent imaging advances have established the radiological fingerprint of some of these neoplasms, and several chromosomal aberrations have also been identified. Although established approaches along with new surgical and radiotherapeutic approaches remain the main treatment modalities, recent evidence has provided insight into their molecular pathogenesis involving, other than chemotherapy, treatments with targeted agents as in gliomas and craniopharyngiomas bearing BRAF mutations. Development of predictive markers of recurrences may also identify high-risk patients, including proliferative markers and expression of the progesterone receptor in meningiomas, and lead to less aggressive surgery. Owing to the rarity and complexity of these neoplasms, patients should be managed in dedicated centers. Conclusions The diagnosis and management of sellar neoplasms necessitate a multidisciplinary approach. Following evolving recent advances in their diagnosis and therapy, such a multidisciplinary approach needs to be extended to establish evidence-based diagnostic and management plans. We have reviewed nonneuroendocrine neoplasms of the pituitary region and identified novel predictive markers and evolving therapies that could help optimize treatment in a multidisciplinary setting.

Tuberculum sellae meningiomas are midline anterior skull base tumors and account for approximately 10–15% of all intracranial meningiomas. Clinical presentation of tuberculum sellae meningiomas is mainly characterized by visual deficits due to optic chiasm compression or optic canal invasion. Treatment options for TSM typically involve surgical resection of the tumor. The relevant microsurgical anatomy of the suprasellar region was discussed. (1,2). Tumor size, anatomical variations can affect the best approach for these tumors, with several approaches been described to access the suprasellar region as pterional, endoscopic endonasal and supraorbital approach that was the choice for this case (3). Besides the surgical corridor, minimally invasive techniques that preserve the surrounding tissue are becoming increasingly popular and are perfectly suited to deep seated lesions. In this article, we present a surgical video of an exoscopic supraorbital approach for resection of a tuberculum sellae meningioma. This is a case of a 42-year-old right-handed female who presented with headaches and progressive vision loss. Patient presented with tumor growth and surgery was indicated. We chose the minimally invasive supraorbital approach and then used the exoscope as magnification tool visualization tool. Gross total resection and decompression of the optic canals was achieved with improvement of visual field deficits.