What is the recommended workup after an MRI brain shows an empty sella?

Workup After MRI Brain Shows Empty Sella

The recommended workup for an incidental finding of empty sella on brain MRI should include basic hormonal screening to evaluate for potential hypopituitarism, as approximately 30% of patients with empty sella may demonstrate some degree of pituitary dysfunction. 1, 2

Initial Assessment

• Empty sella is typically an incidental finding on imaging studies performed for unrelated reasons, such as headache evaluation 1, 3
• MRI is the preferred diagnostic imaging modality for characterization of empty sella, with high-resolution pituitary protocols providing the best visualization 3, 1
• No additional urgent imaging is needed if MRI already confirms empty sella without other concerning features 1

Hormonal Evaluation

• Basic hormonal screening should include: 1, 4

  • Thyroid function tests (TSH, free T4) to rule out central hypothyroidism
  • Morning cortisol and ACTH to assess adrenal axis
  • Sex hormones (estradiol or testosterone)
  • Prolactin levels
  • IGF-1 (insulin-like growth factor 1)

• The most common hormone abnormalities associated with empty sella include: 5, 4

  • Thyroid hormone deficiencies (48% of cases with hormonal abnormalities)
  • Elevated prolactin levels (28% of cases with hormonal abnormalities)

Clinical Assessment

• Evaluate for symptoms suggesting pituitary dysfunction: 1, 2

  • Fatigue, cold intolerance (suggesting hypothyroidism)
  • Sexual dysfunction, menstrual irregularities
  • Visual changes or field defects
  • Signs of increased intracranial pressure (headache, pulsatile tinnitus)

• Consider ophthalmologic evaluation if there are any visual symptoms or concerns about increased intracranial pressure 2

Follow-up Recommendations

• If initial hormonal screening is normal and the patient is asymptomatic, consider reevaluation at 24-36 months due to the low risk of progression 6
• If hormonal deficiencies are identified, appropriate hormone replacement therapy should be initiated and managed by an endocrinologist 4
• The prognosis for patients with empty sella is generally good, with most remaining asymptomatic 7

Important Considerations

• Avoid attributing unrelated symptoms directly to the empty sella finding without considering more common causes 1, 2
• The height of the adenohypophysis on MRI correlates with the likelihood of hormonal deficits - thinner pituitary tissue is associated with higher risk of hormonal abnormalities 5
• Empty sella may rarely be associated with unusual presentations such as bradycardia in the setting of central hypothyroidism 8
• There is a discrepancy between reported prevalence of pituitary insufficiency in patients with empty sella (ranging from 19-52% in different studies), highlighting the importance of hormonal evaluation 6, 4