Management of Partially Empty Sella
MRI is the preferred diagnostic imaging modality for evaluation and management of partially empty sella, with endocrinologic assessment recommended for all patients to evaluate for potential hormone deficiencies.
Diagnostic Approach
Imaging
MRI with high-resolution pituitary protocol is the gold standard for diagnosis and characterization of empty sella 1
- Well characterized even without IV contrast
- Provides detailed visualization of pituitary gland flattening against sellar floor
- Allows assessment of pituitary stalk and optic chiasm
- Can detect herniation of subarachnoid space into sella turcica
CT scan may be used if MRI is contraindicated 1
- Less sensitive than MRI for detecting pituitary abnormalities
- Useful for evaluating bony structures of the sella
Clinical and Endocrinologic Evaluation
Comprehensive hormonal assessment is essential as up to 40% of patients may have at least one hormone deficiency 2
- Growth hormone
- Thyroid function
- Adrenal function
- Gonadal hormones
- Prolactin
Ophthalmologic evaluation if visual symptoms are present 3
- Visual field testing
- Visual acuity assessment
Management Algorithm
1. Asymptomatic Patients with Normal Hormone Function
- Observation with periodic follow-up
- Hormonal reassessment at 24-36 months due to low risk of progression 2
- No specific treatment required
2. Patients with Hormone Deficiencies
- Hormone replacement therapy based on specific deficiencies 4, 5
- Levothyroxine for hypothyroidism
- Cortisone acetate for hypoadrenalism
- Growth hormone replacement if deficient
- Sex hormone replacement if hypogonadism present
3. Patients with Visual Disturbances
- Surgical intervention may be considered in cases of progressive visual field defects 6
- Endoscopic transsphenoidal approach
- Sellar elevation using implants (e.g., silastic coil)
- Goal is to relieve pressure on optic structures
4. Patients with CSF Rhinorrhea
- Surgical repair of the defect in the sellar diaphragm 5
- Transsphenoidal approach
- Closure of CSF leak
Special Considerations
Primary vs. Secondary Empty Sella
Primary empty sella: Idiopathic, often associated with:
- Obesity
- Hypertension
- Female sex
- Multiparity
- Possible association with idiopathic intracranial hypertension 5
Secondary empty sella: Requires management of underlying cause 5
- Post-surgical
- Post-radiation
- After pituitary apoplexy
- Following treatment of pituitary tumors
Monitoring and Follow-up
- Regular endocrine assessment to detect development of new hormone deficiencies
- Periodic imaging (typically every 2-3 years) to monitor for any changes 2
- Visual field testing if visual symptoms develop
Clinical Pitfalls to Avoid
- Assuming all empty sella cases are benign incidental findings - up to 30% of patients may have hypopituitarism requiring treatment 1
- Missing the association with idiopathic intracranial hypertension - evaluate for headaches and papilledema
- Failure to distinguish between primary and secondary empty sella - management differs based on etiology
- Overlooking subtle hormone deficiencies - comprehensive testing is essential even in apparently asymptomatic patients
Empty sella syndrome represents a heterogeneous clinical entity requiring a multidisciplinary approach involving endocrinology, neurology, and ophthalmology for optimal management 5.