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Basal skull fractures involving the sella turcica
BASAL
SKULL
FRACTURES
INVOLVING
THE
SELLA
TURCICA
E. P. ENGELS, M.D.*
From the Departments of Radiology, Duke University Hospital and the Durham Veterans Administration Hospital, Durham, N.C., U.S.A. RECOGNITION of even minute fractures involving the sella turcica is important since serious immediate and delayed endocrine and neurological changes often occur. Therefore, it is felt worthwhile to illustrate the appearances of some of these uncommon fractures. A lateral view of the skull made with horizontal beam direction and with the patient supine is often of great value in showing these injuries. A fluid level in the sphenoid sinus shown on such a film may give the first indication of a fracture through the cranial base. Furthermore, a severely injured patient need not be turned or moved excessively during positioning for this view provided the proper wafer grid or grid cassette is available. Fractures through the floor or anterior wall of the sella may be linear and undisplaced. Such a fracture (Fig. 1A) was demonstrated in one patient who had a short period of unconsciousness after a road accident. There were no endocrine or neurological sequelae. On the other hand, considerable comminution of the fragments of the floor of the sella may occur. A fifteen year old boy, involved in a car accident, was confused and unconscious for several days. He complained of severe frontal headaches and developed a right abducens nerve palsy. Bloodstained fluid drained from his right ear and cerebro-
spinal fluid drained from his right nostril when his head was flexed forward. He had bitemporal hemianopsia. Pre-operative radiographs of the skull showed marked comminution of the floor of the sella turcica and a depressed fracture through the right anterior clinoid process (Fig. 1B). Exploration of the pituitary fossa revealed compression of the right optic nerve by the depressed right anterior clinoid process. There was a small tear in the optic chiasm and a small blood collection was aspirated from the pituitary fossa. Subsequently, the right abducens nerve palsy disappeared but the bitemporal hemianopsia remains. No other endocrine or neurological abnormalities have been detected at follow up examinations. Considerable separation of the fragments of the floor of the sella may occur. This was observed on skull roentgenograms (Fig. l c) of a twenty-two year old man who sustained multiple fractures through the cranial base. With stereoscopic radiographs (Towne's position), the right posterior clinoid process was seen as a separate displaced fragment (Fig. 2). He was unconscious for two days and bled from both ears. Twelve hours after the accident increasing left abducens and facial nerve palsies developed. These disappeared after three weeks and he was released from the hospital.
* Present address: 1458 G r a h a m C o u r t S.E., Rochester, M i n n e s o t a , U.S.A.
A
B
C
FIG. i Simple linear (A), comminuted (B) and separated fractures (c), through the floor and anterior sella. 177
178
CLINICAL
RADIOLOGY
compression injury when a truck door was slammed on his head. After a short period of unconsciousness, he complained of slight vertigo and of a severe headache behind his eyes. Lateral radiographs of the skull (Fig. 3A) and laminagrams through the sella showed a slightly displaced fracture through the tip of the dorsnm sellae. There were no clinical sequelae. The mechanism of injury is similar to that in a case described by McCullagh and Shaffenburg (1953) in which pituitary insufficiency followed an injury with fracture through the anterior cranial base. In another instance, an eighteen year old high school girl sustained multiple skull fractures in an automobile accident. An oblique fracture line was present at the base of the dorsum sellae (Fig. 3B). She remained in deep coma and expired some eighteen hours after the injury. Fi~. 2 Magnified portion of a Towne's view of skull (from a stereoscopic pair) showing separated right posterior clinoid process (RPC), left anterior clinoid process (LAC), left posterior clinoid process (LPC) and dorsum sellae.
During the next year he experienced progressive weakness, a weight loss of 80 lb., and became anaemic. He lost libido, became impotent and complained bitterly of giddiness. Physical examination showed testicular atrophy, a marked loss of pubic and axillary hair, and soft feminine appearing skin. Treatment with cortisone, desiccated thyroid, and testerone produced an excellent clinical response. Isolated fractures of the dorsum sellae can occur. A twenty year old man sustained a bitemporal
A
SUMMARY The radiographic findings and some clinical features are presented in five patients having basal skull fractures involving the sella turcica. Detection of these injuries may aid in the prompt recognition and treatment of acute or delayed hypopituitarism. Acknowledgements.--The author is indebted to D. L. McRae, M.D., Montreal Neurological Institute, and to H. MacM. White, Junr., M.D., Asheboro, N.C., for their kind advice and permission to use case material. REFERENCE McCULLAGH,E. P., • SCHAFFENBURG,C. A. (1953). J. Clin. Endocr. 13, 1,283.
B FIG. 3 Horizontal (A) and oblique (B) fractures of dorsum seUae. Tempero-parietal fracture line (---+) also shown in (B).
SKULL
FRACTURES
INVOLVING
THE
SELLA
TURCICA
E. P. ENGELS, M.D.*
From the Departments of Radiology, Duke University Hospital and the Durham Veterans Administration Hospital, Durham, N.C., U.S.A. RECOGNITION of even minute fractures involving the sella turcica is important since serious immediate and delayed endocrine and neurological changes often occur. Therefore, it is felt worthwhile to illustrate the appearances of some of these uncommon fractures. A lateral view of the skull made with horizontal beam direction and with the patient supine is often of great value in showing these injuries. A fluid level in the sphenoid sinus shown on such a film may give the first indication of a fracture through the cranial base. Furthermore, a severely injured patient need not be turned or moved excessively during positioning for this view provided the proper wafer grid or grid cassette is available. Fractures through the floor or anterior wall of the sella may be linear and undisplaced. Such a fracture (Fig. 1A) was demonstrated in one patient who had a short period of unconsciousness after a road accident. There were no endocrine or neurological sequelae. On the other hand, considerable comminution of the fragments of the floor of the sella may occur. A fifteen year old boy, involved in a car accident, was confused and unconscious for several days. He complained of severe frontal headaches and developed a right abducens nerve palsy. Bloodstained fluid drained from his right ear and cerebro-
spinal fluid drained from his right nostril when his head was flexed forward. He had bitemporal hemianopsia. Pre-operative radiographs of the skull showed marked comminution of the floor of the sella turcica and a depressed fracture through the right anterior clinoid process (Fig. 1B). Exploration of the pituitary fossa revealed compression of the right optic nerve by the depressed right anterior clinoid process. There was a small tear in the optic chiasm and a small blood collection was aspirated from the pituitary fossa. Subsequently, the right abducens nerve palsy disappeared but the bitemporal hemianopsia remains. No other endocrine or neurological abnormalities have been detected at follow up examinations. Considerable separation of the fragments of the floor of the sella may occur. This was observed on skull roentgenograms (Fig. l c) of a twenty-two year old man who sustained multiple fractures through the cranial base. With stereoscopic radiographs (Towne's position), the right posterior clinoid process was seen as a separate displaced fragment (Fig. 2). He was unconscious for two days and bled from both ears. Twelve hours after the accident increasing left abducens and facial nerve palsies developed. These disappeared after three weeks and he was released from the hospital.
* Present address: 1458 G r a h a m C o u r t S.E., Rochester, M i n n e s o t a , U.S.A.
A
B
C
FIG. i Simple linear (A), comminuted (B) and separated fractures (c), through the floor and anterior sella. 177
178
CLINICAL
RADIOLOGY
compression injury when a truck door was slammed on his head. After a short period of unconsciousness, he complained of slight vertigo and of a severe headache behind his eyes. Lateral radiographs of the skull (Fig. 3A) and laminagrams through the sella showed a slightly displaced fracture through the tip of the dorsnm sellae. There were no clinical sequelae. The mechanism of injury is similar to that in a case described by McCullagh and Shaffenburg (1953) in which pituitary insufficiency followed an injury with fracture through the anterior cranial base. In another instance, an eighteen year old high school girl sustained multiple skull fractures in an automobile accident. An oblique fracture line was present at the base of the dorsum sellae (Fig. 3B). She remained in deep coma and expired some eighteen hours after the injury. Fi~. 2 Magnified portion of a Towne's view of skull (from a stereoscopic pair) showing separated right posterior clinoid process (RPC), left anterior clinoid process (LAC), left posterior clinoid process (LPC) and dorsum sellae.
During the next year he experienced progressive weakness, a weight loss of 80 lb., and became anaemic. He lost libido, became impotent and complained bitterly of giddiness. Physical examination showed testicular atrophy, a marked loss of pubic and axillary hair, and soft feminine appearing skin. Treatment with cortisone, desiccated thyroid, and testerone produced an excellent clinical response. Isolated fractures of the dorsum sellae can occur. A twenty year old man sustained a bitemporal
A
SUMMARY The radiographic findings and some clinical features are presented in five patients having basal skull fractures involving the sella turcica. Detection of these injuries may aid in the prompt recognition and treatment of acute or delayed hypopituitarism. Acknowledgements.--The author is indebted to D. L. McRae, M.D., Montreal Neurological Institute, and to H. MacM. White, Junr., M.D., Asheboro, N.C., for their kind advice and permission to use case material. REFERENCE McCULLAGH,E. P., • SCHAFFENBURG,C. A. (1953). J. Clin. Endocr. 13, 1,283.
B FIG. 3 Horizontal (A) and oblique (B) fractures of dorsum seUae. Tempero-parietal fracture line (---+) also shown in (B).