What are the neurological symptoms of a partially empty sella turcica?

Neurological Symptoms of Partially Empty Sella Turcica

Patients with partially empty sella turcica commonly present with headaches, visual deficits, and endocrine-related neurological symptoms, with up to 30% experiencing hypopituitarism requiring treatment. 1

Primary Neurological Manifestations

Headaches

• Headaches are among the most common neurological symptoms in patients with partially empty sella 2, 3
• These headaches are often progressive and may be related to altered cerebrospinal fluid dynamics 1

Visual Disturbances

• Visual deficits occur frequently, particularly in sellar/suprasellar lesions 4
• Specific visual symptoms include:
  • Visual field defects (may resemble those seen with pituitary tumors)
  • Papilledema (requires mandatory ophthalmologic examination) 1
  • Diplopia (especially when cavernous sinus is affected) 4

Cranial Nerve Involvement

• Altered facial sensation due to cranial nerve deficits (particularly when the cavernous sinus is involved) 4
• Hearing loss may occur in cases with internal auditory canal involvement 4

Endocrine-Related Neurological Symptoms

• Up to 40% of patients with partially empty sella may have at least one hormone deficiency 1
• Endocrine-related neurological symptoms include:
  • Physical asthenia (weakness) 2
  • Cognitive changes associated with hypothyroidism
  • Altered consciousness or confusion in cases of adrenal insufficiency
  • Fatigue and decreased mental alertness with various hormone deficiencies

Idiopathic Intracranial Hypertension Association

Partially empty sella is frequently associated with idiopathic intracranial hypertension (IIH), which can present with:

• Headaches
• Visual obscurations
• Pulsatile tinnitus
• Horizontal tortuosity of the optic nerve (68% sensitivity, 83% specificity) 1
• Posterior globe flattening (56% sensitivity, 100% specificity) 1

Clinical Pearls and Pitfalls

Important Considerations

• A partially empty sella found incidentally requires endocrine evaluation, as up to 30% of patients may have hypopituitarism requiring treatment 1
• MRI with high-resolution pituitary protocols is the gold standard for diagnosis, as CT scans are less sensitive 1
• Comprehensive hormonal evaluation is necessary, as hormone deficiencies may cause neurological symptoms that can be mistaken for other neurological disorders 1

Common Pitfalls

• Failing to distinguish between primary and secondary empty sella syndrome, which requires attention to the underlying cause 1
• Missing the association with pituitary adenomas - an empty enlarged sella may represent a stage in the spontaneous course of some pituitary adenomas 5
• Overlooking the need for ophthalmologic examination to assess for papilledema 1

Diagnostic Approach

1. MRI with high-resolution pituitary protocols (shows flattened pituitary gland against sellar floor, CSF-filled sella turcica) 1
2. Comprehensive hormonal evaluation to identify any deficiencies 1
3. Ophthalmologic examination to assess for papilledema and visual field defects 1
4. Lumbar puncture to measure opening pressure if IIH is suspected 1

While many patients with partial empty sella remain asymptomatic with good prognosis 6, the neurological symptoms can significantly impact quality of life and require appropriate evaluation and management.