From the Guidelines
An empty or partially empty sella turcica on a brain MRI indicates a condition where the pituitary gland appears flattened or smaller than normal, with cerebrospinal fluid filling the space within the sella, which can be associated with hypopituitarism in approximately 30% of patients 1. This finding can be classified as either primary empty sella syndrome (occurring spontaneously) or secondary empty sella (resulting from surgery, radiation, or pituitary infarction). Most cases of empty sella are incidental findings that require no treatment, especially if the patient has no symptoms and normal pituitary function. However, some patients may experience headaches, visual disturbances, or hormonal imbalances if pituitary function is affected.
When hormonal deficiencies are present, specific hormone replacement therapy may be necessary, tailored to the particular hormones that are deficient. For example, thyroid hormone replacement, cortisol replacement, or sex hormone therapy might be required. The condition occurs because increased intracranial pressure or a defect in the diaphragma sellae (the membrane covering the sella) allows cerebrospinal fluid to push down on the pituitary gland, flattening it against the floor of the sella turcica. Regular endocrine follow-up is recommended for patients with empty sella to monitor for any developing hormonal abnormalities, even if initial testing is normal. Some key points to consider include:
- The presence of an empty sella can be an incidental finding, but it may also be associated with underlying conditions such as hypopituitarism 1.
- MRI is the preferred diagnostic imaging modality for evaluation of the pituitary and sellar regions, and can confirm the presence of an empty sella 1.
- The diagnosis of pseudotumor cerebri syndrome, which can be associated with empty sella, is based on a combination of clinical and imaging findings, including papilledema, normal neurological examination, and elevated lumbar puncture opening pressure 1.
From the Research
Definition and Causes of Empty Sella
- An empty sella is defined as a sella that is completely or partly filled with cerebrospinal fluid (CSF), regardless of its size 2.
- Empty sella can be primary, which is a normal anatomical variation, or secondary, which occurs after surgery, irradiation, or medical treatment of pituitary adenoma 2, 3.
- Primary empty sella is usually free from clinical symptoms, but can be associated with headache, obesity, visual disturbance, non-traumatic CSF rhinorrhea, and pituitary insufficiency 2.
Clinical Significance of Empty Sella
- The finding of an empty or partially empty sella on routine MRI of the brain is usually of no clinical significance, especially in normal individuals 4.
- However, empty sella syndrome is defined in the presence of pituitary hormonal dysfunction (more frequently hypopituitarism) and/or neurological symptoms due to the possible coexisting of idiopathic intracranial hypertension 3.
- Empty sella can be associated with hyperprolactinaemia, an endocrine abnormality, and may have a yet-to-be defined role in this condition 5.
Diagnosis and Management
- Magnetic resonance imaging (MRI) is useful in diagnosing empty sella 2.
- A multidisciplinary approach with the integration of endocrine, neurological, and ophthalmological experts is strongly advocated for the proper diagnosis, management, and follow-up of empty sella syndrome 3.
- Non-symptomatic cases require no treatment, but periodical follow-up is necessary 2.
- Surgical treatment is indicated for CSF rhinorrhea, visual disturbance, and severe increased intracranial pressure 2.