What is the management approach for a patient with a partially empty sella (SES) found on imaging?

From the Guidelines

Management of a patient with partially empty sella (PES) found on imaging should be individualized based on symptoms and underlying causes. For asymptomatic patients with incidentally discovered PES, observation with periodic follow-up is typically sufficient, as most cases do not require specific treatment 1. However, patients with symptoms should undergo comprehensive endocrine evaluation, including pituitary function tests (morning cortisol, TSH, free T4, prolactin, LH, FSH, testosterone/estradiol, and IGF-1) to identify any hormonal deficiencies. If hormonal abnormalities are detected, appropriate hormone replacement therapy should be initiated - for example, levothyroxine for hypothyroidism, hydrocortisone for adrenal insufficiency, or sex hormone replacement as needed. Patients with headaches may benefit from analgesics, while those with CSF rhinorrhea require neurosurgical evaluation and possibly surgical repair. Visual disturbances warrant ophthalmological assessment. Regular follow-up with endocrinology is recommended, with imaging repeated every 1-2 years initially to monitor for changes in sellar contents, as suggested by the American College of Radiology 1. This approach is necessary because PES represents a radiological finding where the pituitary gland appears flattened with CSF extension into the sella turcica, which may be associated with intracranial hypertension, previous pituitary pathology, or can occur as a primary phenomenon without clear cause. Key considerations in the management of PES include:

• Comprehensive endocrine evaluation for symptomatic patients
• Appropriate hormone replacement therapy for detected hormonal deficiencies
• Neurosurgical evaluation for CSF rhinorrhea
• Ophthalmological assessment for visual disturbances
• Regular follow-up with endocrinology and periodic imaging to monitor for changes in sellar contents. The use of MRI with high-resolution pituitary protocols is generally considered the gold standard for imaging the pituitary gland in cases of suspected hormone-secreting adenoma, and can help characterize tissue consistency and predict response to therapy 1.

From the Research

Management Approach for Partially Empty Sella

The management approach for a patient with a partially empty sella (SES) found on imaging depends on the presence of symptoms and hormonal deficiencies.

• If the patient is asymptomatic, no treatment may be required, and regular follow-up with imaging and hormonal evaluation may be sufficient 2.
• However, if the patient has symptoms such as headache, hypertension, or visual field defects, or if hormonal deficiencies are present, treatment may be necessary 3.
• Hormonal replacement therapy may be required for patients with hormonal deficiencies, such as hypothyroidism, hypoadrenalism, or growth hormone deficiency 3, 4.
• The diagnosis of empty sella syndrome is typically made through magnetic resonance imaging (MRI) or computed tomography (CT) scans 3, 5, 2.
• In some cases, dynamic endocrine testing may be necessary to evaluate pituitary reserve and detect hormonal abnormalities 4, 6.

Hormonal Evaluation and Testing

• Basic neuroendocrinological testing, including fasting cortisol, free thyroxine (fT4), estradiol or testosterone, insulin-like growth factor 1 (IGF-1), and prolactin, may be recommended for patients with partially empty sella 6.
• The prevalence of pituitary insufficiency in patients with primary empty sella syndrome (PES) is estimated to be around 52% 6.
• However, the data on PES as an incidental finding are too sparse to enable any evidence-based recommendation on the potential indications for hormone testing or its nature and extent 6.

Radiological Diagnosis and Follow-up

• MRI is confirmed to be the gold standard for radiological diagnosis of empty sella 2.
• If no alterations are detected on initial imaging, a careful revaluation at 24-36 months may be suggested due to the low risk of progression to empty sella syndrome 2.
• Regular follow-up with imaging and hormonal evaluation may be necessary to monitor the patient's condition and detect any potential changes or complications 2.