What is the appropriate workup for a patient with a partially empty sella?

From the Guidelines

The appropriate workup for a patient with a partially empty sella should begin with a thorough clinical assessment focusing on symptoms of pituitary dysfunction, followed by laboratory evaluation and imaging studies as needed. The clinical assessment should prioritize symptoms such as fatigue, loss of libido, mood changes, or oligomenorrhea, which may indicate pituitary hormone deficiencies. Laboratory evaluation should include:

• Morning cortisol and ACTH levels to assess adrenal function
• TSH and free T4 to evaluate thyroid function
• LH, FSH, and estradiol (in women) or testosterone (in men) to assess gonadal function
• Electrolytes to rule out any imbalances Dynamic testing, such as the ACTH stimulation test, may be necessary to assess adrenal function, especially if morning cortisol levels are indeterminate 1. Imaging studies should include a dedicated pituitary MRI with contrast to better characterize the empty sella and rule out other sellar pathologies, such as tumors or cysts 1. Visual field testing is recommended if the MRI shows any compression of the optic chiasm. If cerebrospinal fluid rhinorrhea is suspected, beta-2 transferrin testing of nasal discharge should be performed. The workup should be tailored to the patient's presentation, as partially empty sella is often an incidental finding requiring no treatment if hormone function is normal. It is essential to note that up to 30% of patients with an empty sella may demonstrate some degree of hypopituitarism upon testing 1. Therefore, a comprehensive approach, including clinical assessment, laboratory evaluation, and imaging studies, is crucial for the appropriate management of patients with a partially empty sella.

From the Research

Partially Empty Sella Workup

The workup for a patient with a partially empty sella involves a comprehensive evaluation of endocrine function and imaging studies.

• Hormonal evaluation, including free thyroid hormones, thyroid-stimulating hormone, growth hormone, follicular stimulating hormone, luteinizing hormone, cortisol, and prolactin, is essential to identify any endocrine abnormalities 2.
• A magnetic resonance imaging (MRI) scan of the brain is necessary to confirm the diagnosis of partial empty sella syndrome and to rule out other potential causes of endocrine abnormalities 3.
• The workup should also include an assessment of the patient's visual field, as visual field defects can be associated with partial empty sella syndrome 4.

Endocrine Abnormalities

Endocrine abnormalities are common in patients with partial empty sella syndrome.

• Hypocortisolemia, hypothyroidism, hypogonadism, hyperprolactinemia, and growth hormone deficiency have been reported in patients with partial empty sella syndrome 2, 5.
• The high incidence of endocrine abnormalities associated with partial empty sella necessitates the need for prompt evaluation and early replacement of hormones for better quality-of-life 2.

Imaging Studies

Imaging studies, including MRI, are crucial in the diagnosis of partial empty sella syndrome.

• An empty sella turcica is defined as a sella that is completely or partly filled with cerebrospinal fluid, regardless of its size 6.
• The size of the sella turcica can be normal or enlarged, and the empty sella can be primary or secondary to other conditions, such as pituitary adenoma or previous pituitary gland hypertrophy 6.