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Empty Sella Syndrome

Peter Ucciferro; Catherine Anastasopoulou.

Author Information and Affiliations

Last Update: October 26, 2023.

Continuing Education Activity

Empty sella syndrome (ESS), also known as arachnoidocele, is a radiologic finding in which the
sella turcica appears empty due to cerebral spinal fluid (CSF) within the subarachnoid space
herniating into the sella turcica. Subsequently, the pituitary gland contained in the sella turcica is
compressed and flattened, and the pituitary stalk is stretched by the CSF, which fills the space.
Over the years, radiologists noticed a similar phenomenon in CT and MRI brain imaging, further
refining the term empty sella. ESS is the condition associated with this finding that may present
with symptoms including headache and visual changes. ESS is commonly classified into 2
etiologic categories: primary empty sella (PES), which has no identified underlying cause, and
secondary empty sella (SES), which has an identifiable etiology (eg, cerebral trauma and
postpartum pituitary necrosis). ESS can be further subdivided into complete and partial types,
with the latter referring to the sella turcica being less than 50% filled with CSF and the former
being more than 50% filled with CSF.

Due to advances in radiologic technology, the incidence of empty sella has recently increased.
Although empty sella has historically been considered an incidental finding without clinical
significance, recent evidence suggests that patients may have associated symptoms, otherwise
known as ESS, more frequently than previously believed. Consequently, most experts
recommend a thorough evaluation in all patients initially found to have empty sella; reevaluation
in asymptomatic patients may be reasonable also. Symptomatic patients with ESS should be
managed supportively; the type of treatment indicated can vary from pharmacologic (eg, growth
hormone replacement) to surgical (eg, lumbar peritoneal shunt) therapies. Because this condition
is being identified more frequently and may be associated with more symptoms than previously
believed, clinicians should be familiar with this finding and the variety of potential presentations.
This activity will enhance the healthcare professional's competence in diagnosing and managing
empty sella syndrome and highlight the critical need for collaboration among multidisciplinary
team members such as ophthalmology, neurology, and endocrinology clinicians to improve
patient outcomes.

Objectives:

Differentiate between primary and secondary empty sella syndrome and recognize
underlying causes.

Identify the clinical signs and symptoms of empty sella syndrome to facilitate early
diagnosis and intervention.

Select appropriate imaging modalities to confirm and evaluate Empty Sella Syndrome.

Coordinate long-term follow-up and treatment adjustments for patients with this condition.

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Access free multiple choice questions on this topic.

Introduction
Empty sella, also known as arachnoidocele, is a radiologic finding in which the sella turcica
appears empty due to cerebral spinal fluid (CSF) within the subarachnoid space herniating into
the sella turcica. Subsequently, the pituitary gland contained in the sella turcica is compressed
and flattened, and the pituitary stalk is stretched by the CSF, which fills the space.[1][2] Over the
years, the term empty sella was adapted further by radiologists incidentally observing a similar
phenomenon in CT and MRI brain imaging.

Due to advances in radiologic technology, the incidence of empty sella has recently increased.
Although empty sella has historically been considered an incidental finding without clinical
significance, recent evidence suggests that patients may have associated symptoms, otherwise
known as ESS, more frequently than previously believed.[3][4] Consequently, most experts
recommend a thorough evaluation in all patients initially found to have empty sella; reevaluation
in asymptomatic patients may be reasonable also. Symptomatic patients with ESS should be
managed supportively; the type of treatment indicated can vary from pharmacologic (eg, growth
hormone replacement) to surgical (eg, lumbar peritoneal shunt) therapies.[3][5][1][2]

Because this condition is being identified more frequently and may be associated with more
symptoms than previously believed, clinicians should be familiar with this finding and the
variety of potential presentations. This activity enhances the healthcare professional's
competence in the diagnosis and management of ESS and highlights the critical need for
collaboration among multidisciplinary team members such as ophthalmology, neurology, and
endocrinology clinicians to improve patient outcomes.

Etiology
Empty sella is a radiologic finding most often seen incidentally caused by the incompetence of
the diaphragm sellae and the resultant herniation of CSF into the sella turcica.[2] ESS is the
condition associated with this finding that may present with symptoms including headache and
visual changes. ESS is commonly classified into 2 etiologic categories: primary empty sella
(PES), which has no identified underlying cause, and secondary empty sella (SES), which has an
identifiable etiology (eg, cerebral trauma and postpartum pituitary necrosis). ESS can be further
subdivided into complete and partial types, with the latter referring to the sella turcica being less
than 50% filled with CSF and the former being more than 50% filled with CSF.[3][5]

The etiology of PES is primarily considered idiopathic; however, there may be some genetic
association in individuals with defects resulting in an incompetent diaphragm sellae. In contrast,
SES etiologies include surgery, trauma, radiation, hemorrhage, infection, or infarction of the
pituitary gland and can occur at any time in an individual's life.[2]

Epidemiology
Empty sella was historically considered a rare entity. The incidence has recently increased, most
likely due to advances in imaging studies.[4] Still, the reported incidence is present in 6% to
20% of autopsy cases and is also estimated to be present in around 38% of patients undergoing
neuroimaging, more often on MRI than CT.[3] Empty sella occurs more than 5 times more
frequently in women. Furthermore, ESS is also more common in obese patients and individuals

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aged 40 to 60.[6][7] The incidence of ESS, with associated hormonal abnormalities, is estimated
to occur in 40% of patients.[3]

Pathophysiology
ESS falls into 2 categories: PES and SES. PES is the less common of the 2 entities. Currently, its
cause is not entirely understood. Still, researchers have proposed several mechanisms, including
incompetence or complete absence of the diaphragm sellae, chronic intracranial hypertension,
small vessel disease, and temporary expansion followed by regression of the pituitary gland.
[4] Congenital incompetent diaphragm sellae is thought to be a potential pathophysiologic cause
of PES, with the anomalous diaphragm sellae allowing the accumulation of CSF into the sella
turcica, causing remodeling and enlargement of the sella turcica and flattening of the pituitary
gland.[3]

Intracranial hypertension is also thought to increase the likelihood of herniation of CSF into the
sella turcica, especially if the diaphragm sellae is already compromised. The most common
neuroimaging finding in patients with idiopathic intracranial hypertension, known as
pseudotumor cerebri, is empty sella.[8] Many pathologies causing increased CSF pressures
correlate with PES, including brain tumors, idiopathic pseudotumor cerebri, intracranial
thrombosis, and hydrocephalus. The resolution of empty sella on imaging after treatment of
intracranial hypertension illustrates further evidence that intracranial hypertension can cause
empty sella.[9]

Another proposed pathophysiologic mechanism causing empty sella involves

an initial enlargement of the pituitary gland followed by a later decrease in gland size, creating a
space where CSF can accumulate.[10] Examples include an expected increase in pituitary
volume during pregnancy and lactation, followed by spontaneous regression during menopause
in women. However, SES, which is more common than PES, can result from various conditions
affecting the pituitary gland, including treatment of a pituitary adenoma with medications,
surgery, or radiotherapy; spontaneous regression of the pituitary gland; postpartum pituitary
necrosis; or lymphocytic hypophysitis.[7]

History and Physical

Although empty sella is often identified incidentally on diagnostic imaging performed for issues
not involving the pituitary, patients are frequently diagnosed with visual, neurologic, or hormonal
conditions, though the clinical association remains unclear. For instance, ESS has been identified
in approximately 40% of individuals with hormonal abnormalities and in up to 94% of patients
with intracranial hypertension.[2][3] Therefore, most experts recommend a comprehensive
evaluation, even in asymptomatic patients.

In any patient, a thorough clinical history and physical should be obtained. A complete medical
history, including obstetric and surgical history, is essential as a clinician may find an underlying
etiology for SES (eg, pituitary surgery, recent pregnancy, traumatic head injury, or radiation
treatment). History and physical exam findings are typically normal in patients with
asymptomatic empty sella because the endocrine function is usually intact. However, in patients
with ESS, common symptoms include headache and visual disturbances (eg, diplopia and
decreased acuity). Other reported symptoms include dizziness, syncope, amenorrhea,
galactorrhea, erectile dysfunction, polydipsia, and polyuria.[3][2] Spontaneous CSF rhinorrhea is

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also possible, though rare.[11] In recent case reports, rare patients have had unusual signs and
symptoms such as hyponatremia and cognitive impairment (eg, dementia).[12][13]

Physical exam findings of ESS can be normal or include features such as hypertension, endocrine
abnormalities (eg, gynecomastia, acromegaly, and signs of hypogonadism), and papilledema.
Findings associated with obesity are frequently present, including sleep apnea and increased
BMI.[2][3]

Evaluation
Imaging Studies

Clinicians can diagnose empty sella when characteristic findings are seen on diagnostic imaging,
typically a head CT or MRI. Diagnostic findings on imaging consist of CSF filling the sellar
space, and the remaining pituitary gland is flattened against the sellar floor (see Image. Empty
Sella on MRI). The total pituitary volume is often reduced to less than 611.21 mm3. The bony
structure of the sella also often appears enlarged. Partial empty sella refers to a sella turcica filled
less than 50% with CSF, and complete empty sella refers to a sella filled to more than 50% with
CSF; the thickness of the remnant pituitary tissue is ≤2 mm.[2][3]

Laboratory Studies

Testing the entire pituitary axis is appropriate and highly recommended in patients with ESS after
diagnosis; however, society-based guidelines are currently lacking.[14][1][15] The pituitary
function can be normal despite the abnormal appearance of the pituitary gland. However, A
recent study found that up to half of individuals with PES have some level of pituitary
insufficiency.[16] Hyperprolactinemia and growth hormone deficiency appear to be the 2 most
common laboratory findings in patients with empty sella.[7][5]

Hyperprolactinemia is present in 10% to 17% of cases resulting from a microprolactinoma or

functional hyperprolactinemia.[6][5] Growth hormone deficiency is identified in 4% to 60% of
patients, but the clinical significance in adults is unclear.[6][14] Furthermore, gonadotropin
deficiency is seen in 2% to 32% of patients, while adrenocorticotropin, thyroid-stimulating
hormone, and antidiuretic hormone deficiencies are seen in about 1% of individuals with empty
sella.[14] Therefore, most experts recommend that diagnostic studies be obtained to assess for
endocrine dysfunction. The laboratory studies suggested for the evaluation of pituitary function
in any patient found to have empty sella include:[3]

Adrenal axis: Early morning fasting cortisol levels are a screening option for
adrenocorticotropin (ACTH) deficiency, and overtly low cortisol levels <3.0 mcg/dL are
consistent with adrenal insufficiency.[17] Morning cortisol levels >11.0 mcg/dL, though
some authors suggest 14.0 mcg/dL, make adrenal insufficiency very unlikely; morning
cortisol levels of 3.1 to 11.0 mcg/dL are indeterminant and can warrant further testing,
such as ACTH stimulation testing. If the morning cortisol level is low, an ACTH level
should be obtained and correlated to the low morning cortisol level to help differentiate
primary from secondary adrenal insufficiency. Metyrapone testing can also assist in this
diagnosis. If corticosteroid excess is suspected, an ACTH level again must be correlated
with cortisol level, and a workup for Cushing disease should be the next step.[2][5]

Thyroid axis: Morning levels of thyroid-stimulating hormone with free thyroxine (T4)
should be evaluated simultaneously.[5]

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Reproductive axis: In premenopausal women with regular menses, gonadotropin and

estradiol levels are unnecessary. Women with irregular or absent menses should have
follicle-stimulating hormone and luteinizing hormone with estradiol levels assessed;
postmenopausal women most likely do not. A testosterone level with simultaneous
luteinizing hormone and follicle-stimulating hormone levels should be obtained in men.[5]

Prolactin: Prolactin levels should be evaluated as prolactin abnormalities are prevalent,

with hyperprolactinemia found more than Prolactin deficiency. Prolactin elevations can
also be seen in many conditions unrelated to ESS (eg, medications and pregnancy).
Therefore, abnormalities must be correlated with the entire clinical presentation.

Growth hormone, excess or deficiency: Growth hormone has a short half-life and is
pulsatile throughout the day, so measuring serum levels is not a common practice. Insulin-
like growth factor 1 can be used instead as a screening measure. However, normal insulin-
like growth factor 1 levels do not rule out growth hormone deficiency. Some experts
recommend stimulation testing to rule out the possibility of growth hormone deficiency.
[14] The gold standard testing for growth hormone deficiency is the insulin tolerance test.
Additional testing options include the growth hormone-releasing hormone plus arginine
test, the glucagon stimulation test, and the macimorelin test.[18]

Antidiuretic hormone: Antidiuretic hormone levels are not typically measured, but the
clinician should inquire about the frequency of urination, including nocturia, to rule out the
possibility of diabetes insipidus. If suspicious of diabetes insipidus, serum sodium, serum
osmolality, and urine osmolality should be obtained. In rare case reports, hyponatremia
was the presenting sign of empty sella.[12]

Treatment / Management
While no established guidelines for managing ESS exist, most experts advise providing
supportive care for symptomatic individuals. If hormone imbalances are identified, treatment is
tailored to address these specific issues. For example, individuals with hypopituitary impairment
may receive cortisol replacement therapy, while those with hyperprolactinemia could benefit
from dopamine agonist treatment.[3][1][2][19] Treatment options for intracranial hypertension in
patients include pharmacologic therapies like oral acetazolamide (250-500 mg daily) or escin
(100-250 mg daily) and surgical placement of a ventricular-peritoneal shunt. The choice among
these options depends on clinical indications and guideline recommendations. Additionally,
ongoing follow-up is essential to monitor any underlying conditions.[5][3]

For asymptomatic individuals without hormone abnormalities, there is limited evidence of

clinically significant progression.[16][3] Recommendations for managing such cases are scarce,
but some sources suggest periodic clinical assessments and diagnostic studies every 2 to 3 years
or as needed.[5][3]

Differential Diagnosis
Empty sella is a radiologic finding and diagnosis. Some differential diagnoses include:

Pituitary tumors

Idiopathic pseudotumor cerebri

Intracranial thrombosis

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Hydrocephalus

Pituitary cystic lesions

Congenital pituitary abnormalities

cystic prolactinomas

Craniopharyngioma

Arachnoid cyst [20][2][5][9]

Prognosis
EES, usually benign, does not impact life expectancy. The prognosis depends on the specific
hormone imbalance if present. Based on current evidence, asymptomatic individuals without
hormone abnormalities typically show minimal clinical progression.[16][3]

Complications
As mentioned earlier, potential empty sella complications include partial or complete
hypopituitarism or hormone overactivity. Furthermore, patients with primary empty sella (eg,
Cushing disease) and radiographic disruption of the pituitary stalk may experience worse
outcomes following pituitary surgery.[21][22]

Deterrence and Patient Education

Patients cannot take specific actions to prevent this occurrence, but they should understand the
importance of assessing their hormone levels at the initial diagnosis. Additionally, asymptomatic
individuals without signs of hormone abnormalities should be informed that there is limited
evidence of significant clinical progression. However, they should seek periodic clinical
evaluations and diagnostic studies if clinically indicated.[16][3][5]

Enhancing Healthcare Team Outcomes

ESS is a rare condition typically discovered by chance during brain imaging when evaluating
complaints like headaches. Although only a small number of these patients have hormone
deficiencies, performing a comprehensive pituitary hormone assessment upon diagnosis and
referring patients to an endocrinologist are essential.

The best approach to managing ESS involves an interprofessional team of specialized and
primary care clinicians who provide ongoing follow-up, educate patients and their families, and
coordinate care. This collaborative effort should also include technicians responsible for imaging
and laboratory tests. Given the increasing incidence and various presentations of ESS, healthcare
professionals should continue to work together across disciplines, such as ophthalmology,
neurology, and endocrinology, to diagnose and assess ESS patients accurately, ultimately
improving their outcomes.

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

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02/01/24, 22.20 Empty Sella Syndrome - StatPearls - NCBI Bookshelf
Figure

Empty Sella on MRI. Cerebral spinal fluid fills the sella

turcica and empty pituitary gland. Image courtesy S Bhimji,
MD

References
1. Auer MK, Stieg MR, Crispin A, Sievers C, Stalla GK, Kopczak A. Primary Empty Sella
Syndrome and the Prevalence of Hormonal Dysregulation. Dtsch Arztebl Int. 2018 Feb
16;115(7):99-105. [PMC free article: PMC5842341] [PubMed: 29510819]
2. Miljic D, Pekic S, Popovic V. Empty Sella. In: Feingold KR, Anawalt B, Blackman MR,
Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra
S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère
B, Levy M, McGee EA, McLachlan R, New M, Purnell J, Sahay R, Shah AS, Singer F,
Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet].
MDText.com, Inc.; South Dartmouth (MA): Aug 1, 2021. [PubMed: 30321014]
3. Carosi G, Brunetti A, Mangone A, Baldelli R, Tresoldi A, Del Sindaco G, Lavezzi E, Sala E,
Mungari R, Fatti LM, Galazzi E, Ferrante E, Indirli R, Biamonte E, Arosio M, Cozzi R,
Lania A, Mazziotti G, Mantovani G. A Multicenter Cohort Study in Patients With Primary
Empty Sella: Hormonal and Neuroradiological Features Over a Long Follow-Up. Front
Endocrinol (Lausanne). 2022;13:925378. [PMC free article: PMC9259926] [PubMed:
35813618]
4. Chen T, Li G, Wu D, Xie B, Feng Y, Xiao S, Li J, Liu Y, Yang J, Li X. Primary empty sella:
The risk factors and associations with the cerebral small vessel diseases-An observational
study. Clin Neurol Neurosurg. 2021 Apr;203:106586. [PubMed: 33730618]
5. De Marinis L, Bonadonna S, Bianchi A, Maira G, Giustina A. Primary empty sella. J Clin
Endocrinol Metab. 2005 Sep;90(9):5471-7. [PubMed: 15972577]
6. Chiloiro S, Giampietro A, Bianchi A, Tartaglione T, Capobianco A, Anile C, De Marinis L.
DIAGNOSIS OF ENDOCRINE DISEASE: Primary empty sella: a comprehensive review.
Eur J Endocrinol. 2017 Dec;177(6):R275-R285. [PubMed: 28780516]
7. Guitelman M, Garcia Basavilbaso N, Vitale M, Chervin A, Katz D, Miragaya K, Herrera J,
Cornalo D, Servidio M, Boero L, Manavela M, Danilowicz K, Alfieri A, Stalldecker G,
Glerean M, Fainstein Day P, Ballarino C, Mallea Gil MS, Rogozinski A. Primary empty sella
(PES): a review of 175 cases. Pituitary. 2013 Jun;16(2):270-4. [PubMed: 22875743]
8. Saindane AM, Lim PP, Aiken A, Chen Z, Hudgins PA. Factors determining the clinical
significance of an "empty" sella turcica. AJR Am J Roentgenol. 2013 May;200(5):1125-31.
[PubMed: 23617499]
9. Zagardo MT, Cail WS, Kelman SE, Rothman MI. Reversible empty sella in idiopathic
intracranial hypertension: an indicator of successful therapy? AJNR Am J Neuroradiol. 1996
Nov-Dec;17(10):1953-6. [PMC free article: PMC8337556] [PubMed: 8933886]
10. Akkus G, Sözütok S, Odabaş F, Onan B, Evran M, Karagun B, Sert M, Tetiker T. Pituitary
Volume in Patients with Primary Empty Sella and Clinical Relevance to Pituitary Hormone
Secretion: A Retrospective Single Center Study. Curr Med Imaging. 2021;17(8):1018-1024.
[PMC free article: PMC8653417] [PubMed: 34036923]
11. Schlosser RJ, Bolger WE. Spontaneous nasal cerebrospinal fluid leaks and empty sella
syndrome: a clinical association. Am J Rhinol. 2003 Mar-Apr;17(2):91-6. [PubMed:
12751703]
12.

https://www.ncbi.nlm.nih.gov/books/NBK541002/ 7/8
02/01/24, 22.20 Empty Sella Syndrome - StatPearls - NCBI Bookshelf

Takkavatakarn K, Wipattanakitcharoen A, Katavetin P, Eiam-Ong S. Severe hyponatremia as the

presenting manifestation of primary empty sella syndrome. Clin Case Rep. 2022
Feb;10(2):e05369. [PMC free article: PMC8813584] [PubMed: 35140964]
13. Bestepe N, Aydin C, Tam AA, Ercan K, Ersoy R, Cakir B. EMPTY SELLA IN A PATIENT
WITH CLINICAL AND BIOCHEMICAL DIAGNOSIS OF ACROMEGALY. Acta
Endocrinol (Buchar). 2022 Jan-Mar;18(1):97-101. [PMC free article: PMC9365410]
[PubMed: 35975262]
14. Giustina A, Aimaretti G, Bondanelli M, Buzi F, Cannavò S, Cirillo S, Colao A, De Marinis
L, Ferone D, Gasperi M, Grottoli S, Porcelli T, Ghigo E, degli Uberti E. Primary empty
sella: Why and when to investigate hypothalamic-pituitary function. J Endocrinol Invest.
2010 May;33(5):343-6. [PubMed: 20208457]
15. Zuhur SS, Kuzu I, Ozturk FY, Uysal E, Altuntas Y. Anterior pituitary hormone deficiency in
subjects with total and partial primary empty sella: do all cases need endocrinological
evaluation? Turk Neurosurg. 2014;24(3):374-9. [PubMed: 24848177]
16. Kuo M, Maya MM, Bonert V, Melmed S. Prospective Evaluation of Incidental Pituitary
Imaging Findings in the Sella Turcica. J Endocr Soc. 2021 Feb 01;5(2):bvaa186. [PMC free
article: PMC7759030] [PubMed: 33392424]
17. Chen HC, Sung CC. A young man with secondary adrenal insufficiency due to empty sella
syndrome. BMC Nephrol. 2022 Feb 25;23(1):81. [PMC free article: PMC8876128]
[PubMed: 35216554]
18. Garcia JM, Biller BMK, Korbonits M, Popovic V, Luger A, Strasburger CJ, Chanson P,
Medic-Stojanoska M, Schopohl J, Zakrzewska A, Pekic S, Bolanowski M, Swerdloff R,
Wang C, Blevins T, Marcelli M, Ammer N, Sachse R, Yuen KCJ. Macimorelin as a
Diagnostic Test for Adult GH Deficiency. J Clin Endocrinol Metab. 2018 Aug
01;103(8):3083-3093. [PubMed: 29860473]
19. Alexandraki KI, Grossman A. Management of Hypopituitarism. J Clin Med. 2019 Dec
05;8(12) [PMC free article: PMC6947162] [PubMed: 31817511]
20. Gadelha MR, Wildemberg LE, Lamback EB, Barbosa MA, Kasuki L, Ventura N. Approach
to the Patient: Differential Diagnosis of Cystic Sellar Lesions. J Clin Endocrinol Metab.
2022 May 17;107(6):1751-1758. [PubMed: 35092687]
21. Mehta GU, Bakhtian KD, Oldfield EH. Effect of primary empty sella syndrome on pituitary
surgery for Cushing's disease. J Neurosurg. 2014 Sep;121(3):518-26. [PubMed: 24857241]
22. Winograd E, Kortz MW, Lillehei KO. Radiographic pituitary stalk disruption: A rare
sequela of secondary empty sella syndrome. Surg Neurol Int. 2021;12:385. [PMC free
article: PMC8422539] [PubMed: 34513152]
Disclosure: Peter Ucciferro declares no relevant financial relationships with ineligible companies.

Disclosure: Catherine Anastasopoulou declares no relevant financial relationships with ineligible companies.

Copyright © 2023, StatPearls Publishing LLC.

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