What is the management approach for a patient with partially empty sella due to pituitary atrophy?

Management of Partially Empty Sella Due to Pituitary Atrophy

Patients with partially empty sella due to pituitary atrophy require comprehensive hormonal evaluation and targeted hormone replacement therapy for any identified deficiencies, as up to 40% of these patients may have at least one hormone deficiency. 1

Diagnostic Evaluation

Initial Assessment

• Hormonal Testing: All patients should undergo comprehensive pituitary function testing 1, 2:

  • Morning ACTH and cortisol levels
  • TSH and free T4
  • FSH, LH, estradiol (females), testosterone (males)
  • Prolactin
  • Growth hormone and IGF-1

• Imaging:

  • MRI with high-resolution pituitary protocol is the gold standard 1
  • Should show flattened pituitary gland against sellar floor with CSF-filled sella turcica
  • In partial empty sella: <50% CSF filling with pituitary height >2 mm 3

• Clinical Evaluation:

  • Ophthalmologic examination (mandatory to assess for papilledema) 1
  • Visual field testing
  • Blood pressure measurement

Management Approach

1. Hormone Replacement Therapy

Based on specific deficiencies identified during evaluation 1:

• Adrenal Insufficiency (more common in complete than partial empty sella 3):

  • Physiologic doses of steroids (e.g., hydrocortisone 15-25 mg daily in divided doses)
  • Patients should obtain and carry a medical alert bracelet 4

• Hypothyroidism:

  • Levothyroxine replacement (typically 1.6 mcg/kg/day)
  • Note: If both adrenal insufficiency and hypothyroidism are present, steroids must be started BEFORE thyroid hormone to avoid adrenal crisis 4

• Hypogonadism (more common in complete than partial empty sella 3):

  • Males: Testosterone replacement
  • Females: Estrogen/progesterone replacement

• Growth Hormone Deficiency:

  • GH replacement if deficient and clinically indicated

2. Follow-up Monitoring

• Regular Endocrine Evaluation:

  • Periodic reassessment of pituitary function (typically every 6-12 months)
  • More frequent monitoring may be needed after initial diagnosis

• Imaging Follow-up:

  • If no hormonal abnormalities are detected initially, reevaluation at 24-36 months is suggested due to low risk of progression 2

• Symptom Monitoring:

  • Assess for new symptoms of hormone deficiencies at each visit
  • Monitor for headaches, visual changes, or other neurological symptoms

Special Considerations

Partial vs. Complete Empty Sella

• Patients with partial empty sella have lower rates of hormonal abnormalities compared to complete empty sella 3, 5
• Secondary adrenal insufficiency and hypogonadism are significantly more common in complete empty sella 3
• Despite lower risk, all patients with partial empty sella should still undergo hormonal testing as affected-axis rates often exceed 10% 3

Prognosis

• Most patients with partial empty sella have good prognosis and remain asymptomatic 1
• The condition is generally stable but requires monitoring for development of new hormonal deficiencies

Common Pitfalls to Avoid

1. Overlooking hormonal deficiencies: Up to 30% of patients with empty sella may have hypopituitarism requiring treatment 1

2. Failure to distinguish between primary and secondary empty sella: Secondary causes (e.g., previous surgery, radiation, exogenous hormone use) require attention to the underlying cause 1, 6

3. Starting thyroid replacement before steroid replacement: In patients with both adrenal insufficiency and hypothyroidism, always start steroids first to prevent adrenal crisis 4

4. Inadequate follow-up: Even if initially normal, hormonal function should be periodically reassessed as deficiencies may develop over time

5. Missing associated conditions: Carefully evaluate for increased intracranial pressure in atypical presentations 1