Is urgent workup needed for a patient with a headache and incidental finding of partially empty sella (sella turcica) but no symptoms of pituitary dysfunction?

Management of Incidental Partially Empty Sella in a Patient with Headache

Urgent workup is not necessary for a patient with headache and an incidental finding of partially empty sella when there is no history or symptoms of pituitary dysfunction. 1

Understanding Empty Sella

• Empty sella (ES) is a radiographic finding where cerebrospinal fluid fills the sella turcica, causing compression of the pituitary gland 2
• Partially empty sella is typically an incidental finding on imaging studies performed for unrelated reasons, such as headache evaluation 1, 2
• While approximately 30% of patients with empty sella may demonstrate some hypopituitarism upon testing, most remain asymptomatic 1

Clinical Assessment

• In the absence of symptoms suggesting pituitary dysfunction, the partially empty sella finding is likely unrelated to the patient's headache 1, 2
• Key symptoms that would warrant more urgent evaluation include:
  • Visual changes (uncommon in empty sella syndrome) 1
  • Signs of hormonal deficiencies such as fatigue, cold intolerance, or sexual dysfunction 1, 3
  • Polyuria and polydipsia (suggesting diabetes insipidus) 4
• Headache alone is a common symptom that may be coincidental rather than related to the empty sella 5

Recommended Approach

1. Basic Hormonal Screening (non-urgent):

   • Thyroid function tests (TSH, free T4) to rule out central hypothyroidism 1, 2
   • Morning cortisol and ACTH to assess adrenal axis 1
   • Sex hormones appropriate for patient's age and gender 1

2. Imaging Interpretation:

   • MRI is the preferred imaging modality for characterizing empty sella 1
   • No additional urgent imaging is needed if MRI already confirms partially empty sella without other concerning features 1

3. Follow-up Plan:

   • Routine endocrine follow-up to monitor for development of pituitary dysfunction 2, 6
   • Ophthalmologic evaluation can be arranged non-urgently to assess for papilledema 2

Important Considerations

• Empty sella syndrome has an excellent prognosis; most patients never develop significant symptoms 2, 6
• The finding of partially empty sella should not delay appropriate evaluation and management of the patient's headache, which likely has a different etiology 5
• If hormonal testing reveals deficiencies, then appropriate hormone replacement should be initiated, but this is not an urgent intervention in the absence of symptoms 1, 6

Pitfalls to Avoid

• Attributing headache symptoms directly to empty sella without considering more common headache etiologies 5
• Ordering unnecessary urgent tests that won't change immediate management 1, 2
• Missing rare but important hormonal deficiencies by not performing appropriate screening 1, 3