From the Guidelines
The protocol for evaluating a possible empty sella syndrome (ESS) diagnosis typically involves MRI imaging of the pituitary without contrast as the initial diagnostic test, as it can reliably characterize an empty sella even without IV contrast 1. This approach is based on the most recent and highest quality study, which emphasizes the importance of MRI in evaluating the pituitary and sellar regions. The use of high-resolution pituitary protocols allows for accurate depiction of anatomy and pathologies involving the pituitary gland, infundibulum, optic chiasm, and vascular structures.
Key Components of the Protocol
- MRI imaging of the pituitary without contrast is the preferred initial diagnostic test
- Comprehensive hormonal testing to assess pituitary function, including measurement of:
- Prolactin
- Thyroid hormones (TSH, free T4)
- Adrenal function (morning cortisol, ACTH)
- Growth hormone (IGF-1)
- Sex hormones (estradiol/testosterone, FSH, LH)
- Visual field testing to assess for any compression of the optic chiasm
- Monitoring for primary (idiopathic) and asymptomatic cases, while secondary empty sella may require further evaluation and management
Management of Hormonal Deficiencies
If hormonal deficiencies are identified, appropriate hormone replacement therapy should be initiated, such as:
- Hydrocortisone 15-25 mg daily in divided doses for adrenal insufficiency
- Levothyroxine 1.6 mcg/kg/day for hypothyroidism
- Sex hormone replacement as needed
- Growth hormone replacement if indicated, as suggested by studies on hypopituitarism 1
Importance of Accurate Diagnosis
Accurate diagnosis and management of empty sella syndrome are crucial to prevent long-term complications and improve quality of life. The condition can be associated with other neuroimaging features, such as increased tortuosity of the optic nerve and enlarged optic nerve sheath, which should be evaluated and managed accordingly 1.
From the Research
Diagnosis of Empty Sella Syndrome (ESS)
The protocol for a possible ESS diagnosis involves several steps, including:
- Magnetic resonance imaging (MRI) to confirm the presence of an empty sella, which is defined as a sella that is completely or partly filled with cerebrospinal fluid (CSF) 2
- Distinguishing between primary and secondary empty sella, with primary empty sella being an idiopathic disease and secondary empty sella occurring after treatment of pituitary tumors or other pituitary pathologies 3
- Evaluation of pituitary function, including tests for thyroid-stimulating hormone (TSH), free thyroxine (FT4), and other hormone levels 4, 5, 6
- Assessment of clinical symptoms, such as headache, obesity, visual disturbance, non-traumatic CSF rhinorrhea, and pituitary insufficiency, which may be associated with ESS 2
Indications for Treatment
Treatment is indicated for symptomatic cases of ESS, including:
- CSF rhinorrhea
- Visual disturbance
- Severe increased intracranial pressure 2
- Hormonal dysfunction, such as hypopituitarism or hyperpituitarism 3, 5, 6
- Cardiac symptoms, such as bradycardia or sick sinus syndrome, which may be associated with ESS 4, 6
Management and Follow-up
A multidisciplinary approach is recommended for the management and follow-up of ESS, including:
- Endocrine evaluation and treatment of hormonal dysfunction
- Neurological evaluation and treatment of associated symptoms
- Ophthalmological evaluation and treatment of visual disturbances
- Regular follow-up with MRI and laboratory tests to monitor the progression of the disease and the effectiveness of treatment 3