Management Approach for Partially Empty Sella
The management of partially empty sella requires comprehensive endocrine evaluation, ophthalmologic assessment, and neurological monitoring, as up to 40% of patients may have at least one hormone deficiency requiring treatment. 1
Diagnostic Evaluation
Initial Assessment
- MRI of the head and orbits: Gold standard for diagnosis 1
- Evaluate pituitary gland size and morphology
- Look for associated findings such as posterior globe flattening, optic nerve sheath distention
- Distinguish between primary and secondary empty sella
Endocrine Evaluation
- Comprehensive hormonal panel to assess for deficiencies 1, 2:
- Growth hormone (GH)
- Thyroid function (TSH, free T4)
- Adrenal function (ACTH, cortisol)
- Gonadal hormones (LH, FSH, testosterone/estradiol)
- Prolactin levels
Ophthalmologic Assessment
- Visual field testing to detect any visual deficits 1
- Evaluation for papilledema, especially important if suspecting associated idiopathic intracranial hypertension (IIH) 1
Neurological Evaluation
- Assessment for headaches and other neurological symptoms 2
- If IIH is suspected, lumbar puncture to measure opening pressure 1
Management Strategy
Asymptomatic Patients
- For incidental findings without hormonal deficiencies or symptoms 3, 4:
- Regular follow-up with endocrine reassessment every 24-36 months
- Patient education about potential symptoms that warrant earlier evaluation
Hormone Replacement Therapy
- Individualized hormone replacement based on specific deficiencies 1:
- Levothyroxine for hypothyroidism
- Cortisone acetate for hypoadrenalism
- Growth hormone replacement if deficient
- Sex hormone replacement for hypogonadism
Management of Associated Conditions
- If associated with IIH 1, 2:
- Weight loss for overweight patients
- Acetazolamide or other diuretics
- Regular ophthalmologic monitoring
- CSF diversion procedures if medical management fails
Surgical Intervention
- Rarely indicated for uncomplicated partially empty sella 5
- May be considered in specific cases:
- Progressive visual field defects despite medical management
- CSF rhinorrhea
- Severe, intractable headaches related to the condition
Follow-up and Monitoring
- Regular endocrine evaluation (at least annually) 1, 3
- Periodic ophthalmologic assessment, especially if visual symptoms develop 1
- Repeat MRI if new symptoms develop or at 24-36 month intervals for asymptomatic patients 3
Important Considerations
- Empty sella is often an incidental finding without clinical implications, but thorough evaluation is necessary to identify those who require treatment 2, 3
- Up to 30% of patients with hypopituitarism requiring treatment may be overlooked without proper evaluation 1
- Children with empty sella are more likely to have clinical symptoms and endocrinopathies than adults 6
- A multidisciplinary approach involving endocrinology, neurology, and ophthalmology is strongly recommended for optimal management 2