Is Optical Coherence Tomography (OCT) indicated for empty sella suggesting high Intracranial Pressure (ICP)?

OCT is Not Indicated for Empty Sella Suggesting High ICP

Optical Coherence Tomography (OCT) is not indicated as a primary diagnostic tool for empty sella suggesting high intracranial pressure (ICP). MRI of the head and orbits is the most appropriate imaging modality for evaluation of suspected increased ICP associated with empty sella syndrome 1.

Diagnostic Approach for Empty Sella and Suspected High ICP

Primary Imaging Modality

• MRI of the head and orbits is the most useful imaging modality for initial evaluation of patients presenting with signs of raised intracranial pressure 1
• MRI provides higher resolution of intracranial and intraorbital structures compared to CT, making it superior for detecting signs of increased ICP 1
• MRI can effectively characterize empty sella without the need for IV contrast 1

Neuroimaging Findings in High ICP

• Empty sella is a recognized neuroimaging feature of raised intracranial pressure 1
• Other associated imaging findings include:
  • Flattening of the posterior globe/sclera (56% sensitivity, 100% specificity) 1
  • Intraocular protrusion of the optic nerve (40% sensitivity, 100% specificity) 1
  • Horizontal tortuosity of the optic nerve (68% sensitivity, 83% specificity) 1
  • Enlarged optic nerve sheath (mean 4.3 mm vs 3.2 mm in controls) 1
  • Smaller pituitary gland size (mean 3.63 mm vs 5.05 mm in controls) 1

Clinical Context of Empty Sella

Association with Intracranial Hypertension

• Empty sella can reflect chronically elevated intracranial pressure and is particularly common in idiopathic intracranial hypertension (IIH) 2
• Studies show that 100% of patients with spontaneous CSF leaks (associated with high ICP) had partially or completely empty sellae, compared to only 11% in the non-spontaneous group 3
• However, empty sella can also be an incidental finding unrelated to increased ICP 2

Clinical Differentiation

• Patients with empty sella due to IIH tend to be younger (mean age 36.1 vs 54.3 years for incidental empty sella) 2
• Headache is significantly more common in IIH-related empty sella (93.3% vs 32.6% in incidental cases) 2
• Visual complaints are more frequent in IIH-related empty sella (66.2% vs 28.3%) 2
• Papilledema is a key clinical finding that should prompt evaluation for increased ICP 4

Role of OCT in ICP Evaluation

• OCT is not mentioned in any of the guidelines as a primary diagnostic tool for empty sella or high ICP 1
• The American College of Radiology appropriateness criteria for orbital imaging and vision loss does not include OCT in its recommendations for evaluating suspected raised intracranial pressure 1
• While OCT may be useful for monitoring changes in the optic nerve and retina, it is not a substitute for neuroimaging in the diagnostic workup of empty sella and suspected high ICP 4

Management Considerations

• When empty sella is found with signs of increased ICP, further evaluation should include:
  • Assessment for papilledema 1
  • Lumbar puncture to measure opening pressure 1
  • Evaluation for secondary causes of pseudotumor cerebri 1
• Treatment should focus on the underlying cause of increased ICP, which may include weight loss in obese patients or CSF diversion procedures in cases of visual deterioration 1
• Empty sella may be reversible with successful treatment of increased ICP 5

Conclusion

When empty sella is identified and high ICP is suspected, MRI of the head and orbits should be the primary imaging modality, not OCT. Clinical evaluation, including assessment for papilledema and other signs of increased ICP, along with appropriate neuroimaging, provides the most comprehensive approach to diagnosis and management.