Syndrome of an empty Turkish saddle

Syndrome of an empty Turkish saddle is a combination of clinical and anatomical signs associated with the penetration of soft The cerebral membrane from the subarachnoid space into the bone formation of the skull is called the Turkish saddle. In this case, the pituitary gland located in the Turkish saddle is depressed to its bottom and walls. The compression of the pituitary gland is accompanied by a violation of its function. This pathological condition develops as a result of a number of reasons. Syndrome of an empty Turkish saddle can be asymptomatic (in such cases, it is discovered accidentally when examined for another disease), and can manifest endocrine, visual, vegetative disorders, as well as changes in the psycho-emotional sphere. Diagnosis of the empty Turkish saddle syndrome requires the use of additional research methods, in particular, magnetic resonance imaging (MRI). Therapeutic tactics can be different, depending on the causes and clinical symptoms of this condition. This article is devoted to the problem of the syndrome of the empty Turkish saddle.

Anatomical foundations of the syndrome of the Turkish saddle

At the base of the human skull is a sphenoid bone. In her body there is a depression called the Turkish saddle. The name this entity received for its external resemblance to the saddles of Turkish horsemen. The pituitary gland is located in the saddle: a small rounded formation that carries out the neuro-endocrine regulation of the body's activity through the production of hormones. Hormones pituitary enter the bloodstream and stimulate the activity of the glands of internal secretion (adrenal glands, gonads, thyroid gland and so on). The production of pituitary hormones is controlled by another important formation of the nervous system - the hypothalamus. The hypothalamus is connected to the pituitary gland by means of the foot. This leg descends into the Turkish saddle and passes through the diaphragm of the saddle, which is like the roof of the saddle. The diaphragm is a dura mater (that is, in fact, a connective tissue) that separates the cavity of the Turkish saddle from the subarachnoid space (space around the brain, filled with cerebrospinal fluid - cerebrospinal fluid). In the diaphragm there is a hole through which the pituitary gland passes, connecting it with the hypothalamus.

The structure of the diaphragm of the saddle, the location of its attachment, the thickness are subject to considerable anatomical fluctuations. And if, for example, this diaphragm is thinned, or underdeveloped, or has a wide opening for the leg, then the subarachnoid space with cerebrospinal fluid, a soft cerebral membrane penetrate into the cavity of the turtle saddle, putting pressure on the pituitary gland. Since this compression process is constant, in the end, this leads to flattening of the pituitary gland, to a decrease in its size and the appearance of the syndrome of the empty Turkish saddle. "Empty" is not in the literal sense of the word, but in the sense that there is no normal pituitary in the saddle. The turpentine saddle itself can not be empty: it fills in this case the cerebrospinal fluid, the remains of the pituitary tissue and even, in some cases, the optic nerves (which just pass over the diaphragm of the saddle). The term "empty" saddle was proposed by the German pathologist B. Bush after he showed at the autopsy almost complete absence of the saddle diaphragm with a very small amount of pituitary tissue inside the Turkish saddle.

According to some reports, up to 10% of people have an underdeveloped diaphragm of the Turkish saddle, but they do not have the syndrome of the empty Turkish saddle. The fact is that for the emergence of the syndrome, one more factor is needed. This is intracranial hypertension. In the case of existing intracranial hypertension, the liquor not only fills the space inside the Turkish saddle, but also exerts considerable pressure on the pituitary gland and its foot. This causes a disturbance in the regulation of the hypothalamus (there is no stimulus from the hypothalamus from the squeezed leg) and provokes problems with the endocrine function of the pituitary gland.

The causes of the syndrome of the Turkish saddle

So, it became clear that the appearance of this disease requires the anatomical inferiority of the saddle diaphragm (which can be congenital or acquired) and intracranial hypertension. Intracranial hypertension may include:

• brain tumors;
• arterial hypertension;
• craniocerebral trauma;
• pathology of internal organs, accompanied by the development of respiratory or heart failure (for example, bronchial asthma, coronary heart disease, and so on);
• infectious diseases of the brain and their consequences (meningitis, encephalitis, arachnoiditis, cystic formations, and so on).

There is another hypothesis of the syndrome of the empty Turkish saddle. It consists in the following: as a result of some states, the size of the pituitary gland first decreases, and only then the space is filled with liquor and envelopes from the supramundane space. In support of this assumption, the following facts say: in multiparous women (or after numerous abortions), the pituitary gland is enlarged in size (that is, compared with the pituitary gland women who have one or two pregnancies in their entire life), that is, initially the volume relationships between the pituitary gland and the Turkish saddle were violated. And with the onset of menopause, the size of the pituitary gland is significantly reduced, but the size of the turtle saddle remains the same. And the "empty" space is filled with liquor and shells located above the saddle. The same mechanism is noted in women who take hormonal contraceptives for a long time. Reduction of the size of the Turkish saddle may be associated with a violation of its blood supply (pituitary infarction, hemorrhage in the thickness of its tissue), autoimmune diseases of the body (for example, autoimmune thyroiditis). All these situations are referred to the so-called primary syndrome of the Turkish saddle. Secondary syndrome of the Turkish saddle is associated with neurosurgical operations in the field of the Turkish saddle or irradiation of this area for a tumor.

Symptoms

Syndrome of an empty Turkish saddle is a condition that does not necessarily manifest itself as clinical symptoms. Sometimes the disease is detected by accident (when performing a computer tomography) when seeking medical help about another pathological condition, and may even be a pathoanatomical finding without any symptoms during life.

The most common syndrome of the Turkish saddle is found in women (80% of the total number of patients), which, perhaps, is associated with a more intensive functioning of the pituitary gland during various hormonal periods of a female life (pregnancy, childbirth, menopause). In general, the clinical picture of the syndrome is characterized by a large number and nonspecific manifestations, the replacement of some signs by other and even spontaneous disappearance of symptoms. The appearance of symptoms of the disease contribute to stressful situations: both acute, single, and chronic, persistent.

All clinical signs of the syndrome of the Turkish saddle can be divided into several groups:

• neurological (including vegetative);
• endocrine;
• visual.

Neurological symptoms

Such patients are often concerned about headache in combination with weakness and rapid fatigue.

It can be:

• headache: the most common symptom of the syndrome of an empty Turkish saddle. This is the most typical complaint of patients. The pain does not have a clear localization, it is variable in intensity, does not depend on the time of day, the position of the body, can arise periodically or disturb almost constantly;
• asthenic syndrome: this concept includes complaints of dizziness and shakiness, poor sleep, general weakness, rapid fatigue, poor tolerance of physical and mental loads, memory impairment;
• changes in the emotional sphere: unmotivated mood swings, inadequate reaction to the surrounding, tearful, bitter or, on the contrary, apathy and lethargy, indifference to everything - all this can have the syndrome of an empty Turkish saddle in its clinical picture;
• vegetative components: most often these are vegetative crises with increased blood pressure, pain in the heart, in the abdomen, a violation of the heart rhythm, shortness of breath, chills, sweating, a sense of fear, diarrhea, fainting. All this can reach a degree of panic attacks.

Endocrine Symptoms

To this group of symptoms include the results of a violation of the hormonal function of the pituitary gland. And it can be both an increase in the production of hormones (hypersecretion), and a decrease (hyposelection). In most cases, the basis of the problem is a disturbance in the regulation of the pituitary gland by the hypothalamus (due to the compression of the pituitary foot). Since the pituitary gland produces several different hormones, these changes can concern either one single hormone, or all at once. The endocrine manifestations of the syndrome of the empty Turkish saddle include:

• Obesity: occurs in 75% of cases of the syndrome of the empty Turkish saddle;
• decreased thyroid function (hypothyroidism): weakness, lethargy, drowsiness, propensity to swelling, constipation, chilliness, brittle hair and nails, dry skin and so on;
• increased thyroid function (hyperthyroidism): sweating, intolerance to heat, a tendency to increase blood pressure pressure, palpitations, bouts of abdominal pain, trembling of the hands, eyelids, increased emotional excitability;
• acromegaly: a disproportionate increase in individual parts of the body against the background of increased production of growth hormone pituitary. It can be manifested by an increase in the wings of the nose, lips, the proliferation of soft tissues in the area of ​​nadbrovy, hands and feet, as well as increased sweating, pain in the muscles and bones;
• giperprolaktinemiyu: violation of the menstrual cycle, infertility in women, sometimes the allocation of breast milk from the mammary glands, a violation of libido. In men, the main manifestations of hyperprolactinaemia are a decrease in libido and potency, gynecomastia (an increase in the size of the mammary glands). Similar symptoms can appear and at a normal level of prolactin, but with an imbalance of other gonadotropins (hormones of the pituitary gland that regulate the activity of the sexual glands) arise more often;
• violation of adrenal function. It can be the Itenko-Cushing syndrome (the deposition of adipose tissue in the face and upper humerus, dryness and pigmentation of the skin in the form of blue-purple stripes on abdomen, hips, mammary glands, increased blood pressure, excessive body hair growth, mental disorders in the form of aggression and depression, and so on).

Endocrine disorders in their severity can range from minor (imperceptible) changes to pronounced clinical forms.

Visual symptoms

According to statistics, visual symptoms occur in 50-80% of cases of the syndrome of an empty Turkish saddle. The appearance of this group of symptoms is due to the fact that in the immediate vicinity of the Turkish saddle there are optic nerves and their cross-chiasm. And these formations in the case of the presence of the syndrome of the empty Turkish saddle are squeezed or their blood supply is disturbed. In this situation, the following symptoms may appear:

• double vision, blurred vision, fuzzy, vagueness of objects;
• sensation of pain behind the eyeball;
• decreased visual acuity;
• changing the fields of vision of a different nature: from the appearance of black spots to the fall of the fields of vision;
• edema and hyperemia of the optic disc when examining the fundus.

It should be borne in mind that none of the above symptoms is specific for the syndrome of the empty Turkish saddle, so the diagnosis of this condition only by clinical signs is simply impossible.

Diagnostics

To establish the diagnosis of the syndrome of an empty Turkish saddle, a magnetic resonance imaging of the brain is necessary. The sensitivity of this method relative to this pathology is almost 100%. Other methods of research (radiography of the skull with an aiming photograph of the area of ​​the Turkish saddle, computed tomography) do not allow to confirm or deny this diagnosis accurately.

A help in diagnosing the syndrome of the Turkish saddle is also the determination in the blood of the level of tropic hormones pituitary gland, but it should be borne in mind that not always this condition is accompanied by hormonal disorders. Normal hormone indices do not exclude the diagnosis of the syndrome of the empty Turkish saddle.

Treatment

If the syndrome of the empty Turkish saddle is an accidental finding in the examination for another disease, that is, does not show any complaints, then treatment is not prescribed. Periodic examination of the doctor is necessary in order not to miss the deterioration of the condition.

If there are hormonal disorders in the form of deficiency in the production of individual hormones, then a substitution hormonal therapy: the missing hormone is injected from the outside (one or more, if necessary).

The available vegetative, asthenic problems are solved with the help of symptomatic therapy (for example, painkillers, sedatives, drugs to lower blood pressure and so on).

Sometimes with the syndrome of an empty Turkish saddle, sagging of the optic nerves and their compression in the aperture of the diaphragm of the Turkish saddle are possible. In this case, the question is raised about surgical treatment, since compression of the optic nerves can lead to irreversible loss of vision. Conducted a stentisphenoidal fixation of the visual crossover, which eliminates its sagging and compression. Also, surgical treatment is indicated in the case when the thinned Turkish saddle oozes spinal fluid (and flows out of the nasal cavity). In this case, the tamponade of the Turkish saddle is produced with a muscle, and the outflow of cerebrospinal fluid ceases.

Thus, the syndrome of an empty Turkish saddle is a highly variable pathology. It may not have any effect, and can cause serious endocrine disorders. And the treatment tactics in this disease can also be different: from the principle of non-intervention with dynamic observation to surgical operation.

Medhelp Clinic, lecture on "The Syndrome of an Empty Turkish Saddle":