What is the recommended further evaluation for a finding of empty sella on Magnetic Resonance Imaging (MRI)?

Recommended Evaluation for Empty Sella Finding on MRI

Patients with an empty sella finding on MRI should undergo comprehensive endocrine evaluation, as approximately 30% may demonstrate some degree of hypopituitarism despite being asymptomatic. 1

Initial Assessment

Clinical Evaluation

• Assess for symptoms of pituitary dysfunction:
  • Fatigue, weakness, dizziness (cortisol deficiency)
  • Cold intolerance, weight gain, dry skin (hypothyroidism)
  • Menstrual irregularities, decreased libido (hypogonadism)
  • Galactorrhea (hyperprolactinemia)
  • Growth issues in younger patients (GH deficiency)
  • Polyuria, polydipsia (diabetes insipidus)

Imaging Characteristics

• Confirm true empty sella appearance on MRI:
  • Flattened pituitary gland against sellar floor
  • CSF-filled sella turcica
  • Intact diaphragma sellae

Hormonal Evaluation

Based on recent evidence, a comprehensive hormonal panel is recommended as the prevalence of pituitary insufficiency in patients with primary empty sella ranges from 19% to 52% 2, 3:

• Anterior pituitary function:

  • Morning cortisol (most common deficiency, seen in up to 62.5% of cases) 4
  • Free T4 and TSH (hypothyroidism in 50% of cases) 4
  • FSH, LH, estradiol (women) or testosterone (men) (hypogonadism in 18.75% of cases) 4
  • Prolactin (hyperprolactinemia in 18.75% of cases) 4
  • IGF-1 (GH deficiency in 12.5% of cases) 4

• Posterior pituitary function:

  • If symptoms of diabetes insipidus are present (polyuria, polydipsia), consider water deprivation test 1, 4

Follow-up Recommendations

• If normal hormonal profile:

  • Reassessment at 24-36 months due to low risk of progression to symptomatic empty sella syndrome 2

• If hormonal abnormalities detected:

  • Prompt hormone replacement therapy to improve quality of life 4
  • Regular endocrine follow-up

Special Considerations

Differential Diagnosis

• Rule out secondary causes of empty sella:
  • Prior pituitary surgery or radiation
  • Pituitary apoplexy
  • Treated pituitary adenomas

Pitfalls to Avoid

1. Assuming empty sella is always benign - While often an incidental finding, up to 30% of patients may have hormonal abnormalities 1
2. Overlooking subtle hormonal deficiencies - Some patients may have subclinical deficiencies requiring dynamic testing
3. Missing coexisting pituitary tumors - In rare cases, small functioning adenomas may be present within an empty sella 5
4. Neglecting follow-up - Even if initially normal, hormonal function should be reassessed periodically 2

MRI remains the gold standard for radiological diagnosis of empty sella, and no additional imaging is typically required unless there are specific concerns about other sellar/parasellar pathologies 1, 2.