A member presented a medical case:
36 year-old woman with head pressure, dizziness, and blurry vision for over 3 years without a diagnosis, and has empty sella on MRI. Doctors do not think there is acromegaly or multiple sclerosis.
Having head pressure, dizziness and blurry vision for more than 3 years. Without a diagnosis or a logical explanation.
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Patient demographics
Gender
female
Age
36
Ethnicity
Hispanic or Latin American
Occupation
x
Chief complaint or problem to solve
Constant Head Pressure is the main symptom. Blurry vision, sometime with brief episodes of blindness. Dizziness or spells, facial numbness, bloodshot eyes, and feeling tired all the time. one CT Scan, and 2 MRI's reveling hyperostosis frontalis interna, a empty sella and multiple prominet perivascular spaces. At first they suspect of MS, but is was negative. Later they suspect of Acromegaly but also was negative. (also sinusitis and Hypertension, was suspect and later negative).
Case history
Constant Head Pressure is the main symptom. Blurry vision, sometime with brief episodes of blindness. Dizziness or spells, facial numbness, bloodshot eyes, and feeling tired all the time. one CT Scan, and 2 MRI's reveling hyperostosis frontalis interna, a empty sella and multiple prominet perivascular spaces. At first they suspect of MS, but is was negative. Later they suspect of Acromegaly but also was negative. (also sinusitis and Hypertension, was suspect and later negative).
Purpose of case discussion
Diagnostic dilemma: "What's the diagnosis?"
Supplemental Materials

Dr. Mark Weisbrod
Ophthalmology
16 doctors agree

In brief: Empty Sella Syndrome

This case most likely constitutes Empty Sella Syndrome (ESS), which can be associated with Pseudotumor Cerebri.
Next step is to get a full endocrinology workup, especially examining pituitary hormone levels. A full ophthalmological/retinal exam and lumbar puncture can also be done to evaluate further. Treatment can then be devised based on these test and examination results.

In brief: Empty Sella Syndrome

This case most likely constitutes Empty Sella Syndrome (ESS), which can be associated with Pseudotumor Cerebri.
Next step is to get a full endocrinology workup, especially examining pituitary hormone levels. A full ophthalmological/retinal exam and lumbar puncture can also be done to evaluate further. Treatment can then be devised based on these test and examination results.
Dr. Mark Weisbrod
Dr. Mark Weisbrod
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4 comments
Dr. Paul Garrett
Great 400 characters on Pseudotumor Cerebri related to ESS, thanks Dr. W. Some Neuro rads use focussed MRI (attn orbits and optic nerves) for suspected PC: http://www.aaojournal.org/article/S0161-6420(98)99039-X/fulltext?refuid=S1090-3798(06)00146-2&refissn=1090-3798&mobileUi=0 AKA, Ophthalmology Sept 1, 1998 Vol 105, Issue 9, Pp 1686–1693.
Dr. Daniel Schainholz
Idiopathic intracranial hypertension without papilledema can cause these false localizing signs too. Consider a drug trial of acetazolamide, methazolamide or other CSF suppressants.
11 doctors agree

In brief: Pseudotumor Cerebri

I fully agree with diagnosis of increased intracranial hypertension, and your correct diagnosis is listed above.
Since there are many causes of this, you will need to have an expert neurologist tackle this, maybe via Concierge visit online here. Your visual issues are likely "obscurational attacks", but this must be treated as you could have risk of permanent visual loss. Suggest a lumbar puncture with monitoring of pressures, and several blood and even some isotope studies. A drug called acetazolamide or glycerol might help dramatically. Get a second opinion ASAP. NO, you do NOT have MS or acromegaly!!!

In brief: Pseudotumor Cerebri

I fully agree with diagnosis of increased intracranial hypertension, and your correct diagnosis is listed above.
Since there are many causes of this, you will need to have an expert neurologist tackle this, maybe via Concierge visit online here. Your visual issues are likely "obscurational attacks", but this must be treated as you could have risk of permanent visual loss. Suggest a lumbar puncture with monitoring of pressures, and several blood and even some isotope studies. A drug called acetazolamide or glycerol might help dramatically. Get a second opinion ASAP. NO, you do NOT have MS or acromegaly!!!
Dr. Bennett Machanic
Dr. Bennett Machanic
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Dr. Nick Debnath
ENT - Head & Neck Surgery
7 doctors agree

In brief: Benign intracranial hypertension

Empty sella associated with increased intracranial pressure leading to displacement of pituitary and optic disk swelling.
May also be associated with pain, spontaneous CSF leaks. Treated with medications usually but sometimes surgical.

In brief: Benign intracranial hypertension

Empty sella associated with increased intracranial pressure leading to displacement of pituitary and optic disk swelling.
May also be associated with pain, spontaneous CSF leaks. Treated with medications usually but sometimes surgical.
Dr. Nick Debnath
Dr. Nick Debnath
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Dr. Ilene Ruhoy
Neurology
6 doctors agree

In brief: IIH?

Symptoms seem consistent with idiopathic intracranial hypertension of which many can have an empty sella on imaging.
Headaches and visual changes are seen most of the time as can other cranial nerve deficits which may account for her episodes of facial numbness. I am not sure if she has had a full ophthalmologic examination to assess for papilledema and a lumbar puncture to measure opening pressure but these tests should be done to rule out this potential diagnosis as there are effective treatments that can be offered to this patient,

In brief: IIH?

Symptoms seem consistent with idiopathic intracranial hypertension of which many can have an empty sella on imaging.
Headaches and visual changes are seen most of the time as can other cranial nerve deficits which may account for her episodes of facial numbness. I am not sure if she has had a full ophthalmologic examination to assess for papilledema and a lumbar puncture to measure opening pressure but these tests should be done to rule out this potential diagnosis as there are effective treatments that can be offered to this patient,
Dr. Ilene Ruhoy
Dr. Ilene Ruhoy
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2 comments
Dr. Daniel Schainholz
Lumbar puncture with dynamic opening pressure manometry may yield the diagnosis of IIH better than a single point measurement.
Dr. Ira Katz
Agree, but please if possible we should rule out central adrenal insufficiency first. If we the vision treatment becomes emergent, I would treat her with stress dose steroids before an invasive procedure m, even a lumbar puncture, given her symptoms.
Dr. Nayana Trivedi
Internal Medicine
5 doctors agree

In brief: Empty sella?

Did she have Endocrine Work up including TRH/ACTH/ assay .
This may be related to it. Allergy testing is other approach one should take. Bothe environmental as well as food

In brief: Empty sella?

Did she have Endocrine Work up including TRH/ACTH/ assay .
This may be related to it. Allergy testing is other approach one should take. Bothe environmental as well as food
Dr. Nayana Trivedi
Dr. Nayana Trivedi
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Dr. Nathaniel Schuster
Pain Management
4 doctors agree

In brief: Refer to ophtho

I agree with pseudotumor cerebri/IIH, which puts her at risk for permanent visual loss.
She needs not just a good fundoscopic exam, but also Humphrey Visual Fields. If this ends up being IIH, he'll need to follow with ophtho, as we'd titrate diuretics and make decisions on shunting based on fundoscopy and HVF, not based on head pain. If headache persists after papilledema resolves after, say, weight loss and titrating diamox, then I'd titrate typical migraine preventive meds (often topamax (topiramate) because of weight loss and some additional carbonic anhydrase inhibition) to headache control.

In brief: Refer to ophtho

I agree with pseudotumor cerebri/IIH, which puts her at risk for permanent visual loss.
She needs not just a good fundoscopic exam, but also Humphrey Visual Fields. If this ends up being IIH, he'll need to follow with ophtho, as we'd titrate diuretics and make decisions on shunting based on fundoscopy and HVF, not based on head pain. If headache persists after papilledema resolves after, say, weight loss and titrating diamox, then I'd titrate typical migraine preventive meds (often topamax (topiramate) because of weight loss and some additional carbonic anhydrase inhibition) to headache control.
Dr. Nathaniel Schuster
Dr. Nathaniel Schuster
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Dr. Muhammad Sethi
Internal Medicine - Endocrinology
4 doctors agree

In brief: For empty sella check pituitary function.

For empty sella, check 8 AM cortisol, TSH, Free T4, prolactin.

In brief: For empty sella check pituitary function.

For empty sella, check 8 AM cortisol, TSH, Free T4, prolactin.
Dr. Muhammad Sethi
Dr. Muhammad Sethi
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Dr. Djamchid Lotfi
Neurology
3 doctors agree

In brief: ?stress related ?

After 3 years and negative investigations major neurological diagnoses are excluded Look into life style events, medications (including contraceptives ) Try mild tranquilizers and/or the effect of Meditation and Yoga

In brief: ?stress related ?

After 3 years and negative investigations major neurological diagnoses are excluded Look into life style events, medications (including contraceptives ) Try mild tranquilizers and/or the effect of Meditation and Yoga
Dr. Djamchid Lotfi
Dr. Djamchid Lotfi
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Dr. Ira Katz
Internal Medicine - Endocrinology
2 doctors agree

In brief: Empty Sella - Why?

Your patient is 36 years old and clearly has empty sella syndrome and some finding consistent with acromegaly.
She does not have it now, but has it been checked more than once? Also was she recently pregnant and could this be a post partum pituitary apoplexy or did she have a tumor in the past that underwent apoplexy. I agree with the above answer, lets get a full good endo w/u and optho exam. LP may be in order to rule in our out pseuodotumor Cerebri. Although, with empty sella the pituitary usually remains functional (it is just squished by the increased pressure) if this is from a pituitary apoplexy she may be symptomatic and she should have the endo w/u which is relatively quick prior to invasive procedures in the event she has central hypothyroidism, easily missed, or central adrenal insufficiency. Most of the labs could even be ordered her on HealthTap.

In brief: Empty Sella - Why?

Your patient is 36 years old and clearly has empty sella syndrome and some finding consistent with acromegaly.
She does not have it now, but has it been checked more than once? Also was she recently pregnant and could this be a post partum pituitary apoplexy or did she have a tumor in the past that underwent apoplexy. I agree with the above answer, lets get a full good endo w/u and optho exam. LP may be in order to rule in our out pseuodotumor Cerebri. Although, with empty sella the pituitary usually remains functional (it is just squished by the increased pressure) if this is from a pituitary apoplexy she may be symptomatic and she should have the endo w/u which is relatively quick prior to invasive procedures in the event she has central hypothyroidism, easily missed, or central adrenal insufficiency. Most of the labs could even be ordered her on HealthTap.
Dr. Ira Katz
Dr. Ira Katz
Thank
2 comments
Dr. Paul Garrett
Thanks Dr. K for perhaps the most complete answer of all. I agree heartily with all you've said. This thread has been opined by so many good Drs. it makes HT look good. We really need pt follow up now. How does that work?
Dr. Ira Katz
Thank you! This is how we do it. We make sure we are in each others networks and communicate back forth here or via physician messaging, which is HIPPA secure. I am thrilled to help in any way possible!
Dr. Paul Garrett
Radiology
2 doctors agree

In brief: Whole lotta nothin on routine MR

Hyperostosis, empty sella and prominent perivascular spaces are all very common and most commonly normal variants.
Episodic blindness may be amaurosis fugax and can presage stroke. This risk could warrant a vascular work-up at least by carotid U/S and possibly cranial MR Angiography, usually a non contrast examination. Pseudotumor cerebri is a very good thought and may require focused MRI study , esp. involving the back of the eye. Some folks look at CSF opening pressures (lumbar puncture aka, spinal tap), but this is controversial. See an old article: http://www.aaojournal.org/article/S0161-6420(98)99039-X/fulltext?refuid=S1090-3798(06)00146-2&refissn=1090-3798&mobileUi=0 Exact distribution and timing of facial numbness is also important info. but not mentioned. The above does not imply specific advice for this patient.

In brief: Whole lotta nothin on routine MR

Hyperostosis, empty sella and prominent perivascular spaces are all very common and most commonly normal variants.
Episodic blindness may be amaurosis fugax and can presage stroke. This risk could warrant a vascular work-up at least by carotid U/S and possibly cranial MR Angiography, usually a non contrast examination. Pseudotumor cerebri is a very good thought and may require focused MRI study , esp. involving the back of the eye. Some folks look at CSF opening pressures (lumbar puncture aka, spinal tap), but this is controversial. See an old article: http://www.aaojournal.org/article/S0161-6420(98)99039-X/fulltext?refuid=S1090-3798(06)00146-2&refissn=1090-3798&mobileUi=0 Exact distribution and timing of facial numbness is also important info. but not mentioned. The above does not imply specific advice for this patient.
Dr. Paul Garrett
Dr. Paul Garrett
Thank
Dr. Michael Kleerekoper
Internal Medicine - Endocrinology

In brief: Dizzy, vision,

Your doctor should have taken care of you over 3 years but it seems that the care was not good enough.
See if a friend or family could recommend a primary doctor who will get your story, examine you, and order labs. When that is complete the doctor will either treat you or send you to specialist. Hope all goes well and please keep me posted.

In brief: Dizzy, vision,

Your doctor should have taken care of you over 3 years but it seems that the care was not good enough.
See if a friend or family could recommend a primary doctor who will get your story, examine you, and order labs. When that is complete the doctor will either treat you or send you to specialist. Hope all goes well and please keep me posted.
Dr. Michael Kleerekoper
Dr. Michael Kleerekoper
Thank
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