What is the treatment approach for a partially empty sella due to pituitary atrophy?

Treatment Approach for Partially Empty Sella Due to Pituitary Atrophy

The treatment of partially empty sella due to pituitary atrophy should focus primarily on comprehensive hormonal evaluation and targeted hormone replacement therapy for any identified deficiencies, as up to 40% of patients may have at least one hormone deficiency. 1

Diagnostic Evaluation

Imaging

• MRI with high-resolution pituitary protocols is the gold standard for diagnosis 1
  • Confirms the presence of partially empty sella (defined as <50% CSF filling with pituitary height >2mm) 2
  • Can show a flattened pituitary gland against the sellar floor and CSF-filled sella turcica
  • Should be repeated at 24-36 months if initial evaluation shows no hormonal abnormalities 3

Hormonal Assessment

A comprehensive hormonal panel should include:

• Morning ACTH and cortisol levels
• TSH and free T4
• FSH, LH, and sex hormones (estradiol in females, testosterone in males)
• Prolactin
• Growth hormone and IGF-1 2

Treatment Algorithm

1. Hormone Replacement Therapy

Based on specific deficiencies identified:

• Adrenal Insufficiency: Physiologic doses of steroids (hydrocortisone 15-25 mg daily in divided doses) 1

  • Patients should obtain and carry a medical alert bracelet
  • This is especially important as secondary adrenal insufficiency is significantly more common in complete empty sella but can occur in partial empty sella as well 2

• Hypothyroidism: Levothyroxine replacement 1

  • Secondary hypothyroidism appears to be more common in male patients 2

• Hypogonadism: Sex hormone replacement therapy 1

  • Secondary hypogonadism is more common in complete empty sella but should be evaluated in partial empty sella as well 2

• Growth Hormone Deficiency: Growth hormone replacement if deficient 1

2. Management of Associated Conditions

• Ophthalmologic examination to assess for papilledema 1
• Evaluation for symptoms of increased intracranial pressure
• Blood pressure monitoring

Follow-up Care

• Regular endocrine evaluations to monitor hormone levels and adjust replacement therapy as needed
• Follow-up MRI at 24-36 months if initial evaluation shows no hormonal abnormalities 3
• More frequent monitoring may be necessary for patients with identified hormone deficiencies

Important Considerations

Prognosis

• Most patients with partial empty sella have a good prognosis and remain asymptomatic 1
• However, careful monitoring is essential as hormonal deficiencies may develop over time

Clinical Pitfalls to Avoid

1. Overlooking hormonal deficiencies: Even though partial empty sella has lower rates of hormonal abnormalities compared to complete empty sella, affected-axis rates often exceed 10% and may reach 50% 2

2. Failing to distinguish between primary and secondary empty sella: Secondary causes (e.g., previous surgery, radiation therapy, or exogenous hormone use) require specific attention to the underlying cause 1, 4

3. Missing multiple hormonal deficiencies: The proportion of cases with two or more affected axes is higher in complete empty sella but can occur in partial empty sella as well 2

4. Neglecting regular follow-up: Even if initial evaluation is normal, patients should be monitored as the condition may progress 3