From the Guidelines
Empty sella syndrome diagnosis should primarily involve MRI imaging to confirm the presence of an enlarged sella turcica filled with cerebrospinal fluid and a thinned pituitary gland, as it is the gold standard imaging technique for this condition. Diagnosis of empty sella syndrome involves a combination of clinical evaluation, laboratory testing, and imaging studies. According to 1, MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluation of the pituitary and sellar regions. This modality can reliably depict anatomy and pathologies involving the pituitary gland, infundibulum, optic chiasm, and vascular structures, and can characterize lesions of the sella, suprasellar cistern, and any cavernous sinus invasion.
Key Diagnostic Steps:
- Clinical evaluation to assess symptoms and potential hormonal deficiencies
- Laboratory tests to assess pituitary function, including measurements of thyroid hormones, cortisol, growth hormone, prolactin, and sex hormones
- MRI imaging to confirm the presence of an empty sella and assess the pituitary gland and surrounding structures
Management Considerations:
- Most cases are asymptomatic and require no treatment beyond regular monitoring
- For patients with hormonal deficiencies, hormone replacement therapy is necessary, which may include levothyroxine for hypothyroidism, hydrocortisone for adrenal insufficiency, sex hormone replacement if needed, and growth hormone replacement in selected cases
- Patients with visual disturbances or cerebrospinal fluid leaks may require neurosurgical intervention, as noted in 1, which discusses various conditions that may affect the pituitary stalk and the hypothalamic-pituitary axis, including empty sella syndrome. Regular follow-up with endocrinology is essential to monitor hormone levels and adjust replacement therapy as needed.
From the Research
Diagnosis of Empty Sella Syndrome
- Empty sella syndrome is characterized by a flattened profile of the pituitary gland, which can be a radiological incidental finding, but when accompanied by endocrine, ophthalmic, and neurological symptoms, it is described as empty sella syndrome 2.
- The incidence of empty sella is about 12% in neuroimaging, and it can reach 35% in clinical practice 2.
- Magnetic nuclear imaging (MRI) is confirmed to be the gold standard for radiological diagnosis of empty sella 2.
Investigations for Empty Sella Syndrome
- Endocrine pituitary disorders, defined as at least one hormone deficit, were reported in 19% to 40% of patients with empty sella syndrome 2.
- Pituitary function testing for somatotroph, lactotroph, gonadotroph, corticotroph, and thyrotroph abnormalities is necessary when suspecting empty sella syndrome 3.
- Clinical and imaging findings, such as age, sex, clinical symptoms, and frequency of previously reported orbital findings, can be used to differentiate patients with chronically elevated intracranial pressure from those with incidental empty sella turcica 4.
Management of Empty Sella Syndrome
- 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 empty sella syndrome 2.
- While an isolated empty sella finding does not require treatment, empty sella syndrome may require pharmacologic or surgical interventions to address hormone deficits or intracranial hypertension 3.
- Targeted hormone replacement as directed by the endocrinologist should align with guidelines and patient-specific needs, and treatment may involve a multidisciplinary collaboration with neurology, neurosurgery, or ophthalmology to address patient symptoms 3.