What is the diagnosis and treatment for partial empty sella syndrome?

From the Guidelines

Partial empty sella syndrome typically requires no specific treatment, but management focuses on addressing any associated hormonal imbalances or symptoms, with a complete endocrine evaluation and hormone replacement therapy as needed, as recommended by the most recent guidelines 1.

Diagnosis and Treatment Recommendations

• Undergo a complete endocrine evaluation to check for pituitary hormone deficiencies, as pituitary hypofunction can be caused by mass effect from extrinsic solid or cystic lesions, or from intrinsic pituitary abnormalities 1.
• If hormonal deficiencies are found, hormone replacement therapy may be necessary:
  • For thyroid deficiency: Levothyroxine, starting at 25-50 mcg daily, adjusted based on TSH levels
  • For adrenal insufficiency: Hydrocortisone, typically 15-25 mg daily in divided doses
  • For growth hormone deficiency: Recombinant human growth hormone, dosage individualized
  • For hypogonadism: Testosterone or estrogen replacement, depending on sex and age
• Manage any associated symptoms:
  • For headaches: Over-the-counter pain relievers or prescribed migraine medications
  • For visual disturbances: Referral to an ophthalmologist for evaluation and management
• Regular follow-up with an endocrinologist for monitoring and adjusting treatment as needed.
• MRI imaging, using high-resolution pituitary protocols, is the preferred diagnostic imaging modality for evaluation of the pituitary and sellar regions, and may be recommended periodically to monitor the condition 1.

Importance of MRI Imaging

• MRI can confirm absence or ectopia of the posterior pituitary gland, and pituitary underdevelopment may be suggested on the basis of imaging 1.
• An empty sella is well characterized on MRI, even without IV contrast, and can help identify any associated lesions or abnormalities 1.
• Understanding the underlying cause and any associated hormonal imbalances is crucial for proper management, and MRI imaging plays a key role in this process 1.

From the Research

Diagnosis of Partial Empty Sella Syndrome

• The diagnosis of partial empty sella syndrome is typically made using magnetic resonance imaging (MRI), which is considered the gold standard for radiological diagnosis 2.
• MRI can show the herniation of the subarachnoid space into the sella turcica and the compression of the pituitary gland against the sella wall 3, 4.
• The incidence of empty sella is about 12% when it comes to neuroimaging, while in clinical practice it can reach 35% 2.

Treatment of Partial Empty Sella Syndrome

• Treatment for partial empty sella syndrome should be individualized, as the clinical features and biochemical abnormalities vary widely among patients 5.
• Patients with partial empty sella syndrome should undergo endocrine, neurologic, and ophthalmologic evaluation at the time of initial presentation and should be monitored as determined by the initial results 5.
• Hormonal pituitary evaluation should be assessed at the moment of diagnosis, along with careful imaging using MRI 2.
• If no alterations are detected, it is suggested to have a careful revaluation at 24-36 months, in relation to the low risk of progression to partial empty sella syndrome 2.
• Endocrine disorders, such as hypopituitarism, should be treated with appropriate hormone replacement therapy 6, 4.

Endocrine Abnormalities

• Endocrine abnormalities are common in patients with partial empty sella syndrome, with 19% to 40% of patients having at least one hormone deficit 2.
• The most common endocrine dysfunction is hyperprolactinemia, followed by isolated growth hormone deficiency 3.
• Other endocrine abnormalities, such as secondary hypothyroidism, can also occur 4.