Next Steps After Finding Empty Sella on MRI Brain
After finding an empty sella on brain MRI, a comprehensive hormonal evaluation is necessary as the next step, since up to 40% of patients may have at least one hormone deficiency. 1
Hormonal Evaluation
A complete endocrine workup should include:
- Morning ACTH and cortisol (to assess adrenal function)
- TSH and free T4 (to assess thyroid function)
- FSH, LH, and estradiol (females) or testosterone (males) (to assess gonadal function)
- Prolactin
- Growth hormone (GH) and insulin-like growth factor-1 (IGF-1)
This comprehensive panel is particularly important because recent research shows that hormonal abnormalities are common in empty sella syndrome, with secondary adrenal insufficiency and hypogonadism being significantly more prevalent in complete empty sella (≥50% CSF filling with pituitary <2mm) compared to partial empty sella (<50% filling with pituitary >2mm). 2
Clinical Assessment
In addition to hormonal testing:
- Ophthalmologic examination is mandatory to assess for papilledema 1
- Blood pressure measurement is crucial as it may indicate underlying hormonal imbalances
- Visual field testing should be performed to detect any visual deficits 1
Distinguishing Between Primary and Secondary Empty Sella
It's important to determine whether the empty sella is:
- Primary (idiopathic, no history of pituitary pathology)
- Secondary (following treatment of pituitary tumors, spontaneous necrosis, infectious processes, autoimmune diseases, or brain trauma) 3
This distinction helps guide further management and follow-up.
Evaluation for Increased Intracranial Pressure
If clinically indicated (especially with headaches or visual symptoms):
- Lumbar puncture to measure opening pressure (diagnostic criterion: >250 mm CSF in adults, >280 mm CSF in children) 1
- CSF composition analysis should be normal in primary empty sella syndrome 1
Follow-up Recommendations
- Regular endocrine evaluation is necessary to monitor for development of hypopituitarism, which can occur in up to 30% of patients with empty sella 1
- MRI follow-up may be needed based on clinical findings and hormonal status
Important Considerations
- The prevalence of pituitary insufficiency in patients with primary empty sella syndrome is reported to be as high as 52% in some studies 4, highlighting the importance of hormonal testing even in asymptomatic patients
- Complete empty sella patients are at higher risk for having multiple affected hormonal axes compared to partial empty sella patients 2
- Secondary hypothyroidism appears to be significantly more common among males with empty sella 2
Management Approach
If hormonal deficiencies are identified:
- Initiate hormone replacement therapy based on specific deficiencies:
- Levothyroxine for hypothyroidism
- Cortisone acetate for hypoadrenalism
- Growth hormone replacement if deficient
- Sex hormone replacement for hypogonadism 1
- Patients with adrenal insufficiency should obtain and carry a medical alert bracelet 1
While many patients with empty sella remain asymptomatic with good prognosis 1, the high prevalence of hormonal abnormalities necessitates thorough evaluation to prevent missed diagnoses and ensure appropriate treatment.