What are the implications of a partially empty sella turcica (sella turcica) on imaging studies?

From the Guidelines

A partially empty sella turcica on imaging is generally a benign finding that often requires no specific treatment, but patients should undergo basic hormonal evaluation to rule out pituitary dysfunction, as indicated by the American College of Radiology appropriateness criteria 1. The condition occurs when cerebrospinal fluid fills part of the pituitary fossa, making the pituitary gland appear flattened or smaller on imaging. While most cases are incidental and asymptomatic, it is essential to evaluate for potential hormonal imbalances, as approximately 30% of patients with an empty sella may demonstrate some degree of hypopituitarism upon testing 1.

Key Considerations

• Basic hormonal evaluation should include measuring prolactin, thyroid hormones, cortisol, and sex hormones to rule out pituitary dysfunction.
• If hormonal deficiencies are detected, specific hormone replacement therapy would be indicated, such as levothyroxine for hypothyroidism, hydrocortisone for adrenal insufficiency, or sex hormone replacement as needed.
• Visual field testing is recommended if the empty sella is large or if there are any visual symptoms, as rarely the condition can be associated with optic chiasm compression.
• MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluation of the pituitary and sellar regions, and can confirm the presence of an empty sella even without IV contrast 1.

Management and Monitoring

• Most patients with partially empty sella require only periodic monitoring with repeat imaging every 1-2 years initially, then less frequently if stable.
• The condition develops either as a primary phenomenon (often in overweight women with hypertension) or secondary to previous pituitary pathology, surgery, radiation, or infarction.
• Patients should be reassured that this is typically not a progressive or dangerous condition but should report any new headaches, visual changes, or symptoms of hormonal imbalance promptly.

From the Research

Implications of Partially Empty Sella Turcica on Imaging Studies

The implications of a partially empty sella turcica on imaging studies can be significant, with various studies highlighting the importance of proper diagnosis and management. Some key points to consider include:

• A partially empty sella turcica can be defined as a sella that is completely or partly filled with cerebrospinal fluid (CSF) 2
• This condition can be primary, meaning it is a normal anatomical variation, or secondary, resulting from surgery, irradiation, or medical treatment of pituitary adenoma 2
• Magnetic resonance imaging (MRI) is a useful tool in diagnosing empty sella turcica, and can help identify associated symptoms such as headache, obesity, visual disturbance, non-traumatic CSF rhinorrhea, and pituitary insufficiency 2, 3
• Asymptomatic empty sella turcica is typically discovered incidentally through imaging, and patients with this condition usually have a good prognosis, with the majority never becoming symptomatic 3
• However, some patients may develop symptoms, and a standardized management protocol is recommended, including endocrine panel evaluation and referral to ophthalmology for formal assessment of papilledema 3

Associated Symptoms and Conditions

Some studies have highlighted the association between partially empty sella turcica and various symptoms and conditions, including:

• Hypopituitarism, which can result from the compression of the pituitary gland against the sella wall 4
• Isolated ACTH deficiency, which can be caused by primary empty sella turcica 5
• Spontaneous resolution of pituitary macroadenoma, which can result in secondary empty sella turcica 4
• Dysopsia, which can be improved with surgical treatment using a silastic coil 6

Management and Treatment

The management and treatment of partially empty sella turcica depend on the presence and severity of symptoms, as well as the underlying cause of the condition. Some studies have recommended:

• Surgical treatment for patients with progressing dysopsia or other significant symptoms 6
• Endoscopic transsphenoidal treatment using a silastic coil for patients with primary empty sella turcica syndrome 6
• Replacement therapy with methylprednisolon for patients with isolated ACTH deficiency 5
• Periodical follow-up for asymptomatic patients to monitor for the development of symptoms or changes in pituitary function 2, 3