What is the primary recommendation for managing empty sella syndrome?

Management of Empty Sella Syndrome

MRI of the sella is the primary recommended imaging modality for diagnosing and evaluating empty sella syndrome, as it can accurately characterize the condition even without intravenous contrast. 1

Understanding Empty Sella

• Empty sella is characterized by herniation of the subarachnoid space into the sella turcica, causing flattening of the pituitary gland 2
• It can be classified as primary (idiopathic) or secondary (following treatment of pituitary tumors, spontaneous necrosis, infections, or trauma) 3
• The condition is often an incidental finding on imaging with an estimated incidence of 12% in neuroimaging studies, but up to 35% in clinical practice 2

Diagnostic Approach

• MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluating empty sella 1
• An empty sella is well characterized on MRI even without IV contrast, making it the most efficient first-line test 1
• CT can detect empty sella but is less sensitive compared to MRI and should not be considered a first-line imaging test 1
• Empty sella can be classified as partial (<50% CSF filling with pituitary >2mm) or complete (≥50% CSF filling with pituitary <2mm) 4

Hormonal Evaluation

• Approximately 30% of patients with empty sella may demonstrate some degree of hypopituitarism upon testing 5, 6
• Basic hormonal screening is recommended and should include:
  • Thyroid function tests (TSH, free T4) to rule out central hypothyroidism 5, 7
  • Morning cortisol and ACTH to assess adrenal axis 5, 7
  • Sex hormones (FSH, LH, estradiol in females, testosterone in males) 5, 7
  • Prolactin and growth hormone/IGF-1 levels 7
• Complete empty sella has a significantly higher proportion of secondary adrenal insufficiency and secondary hypogonadism compared to partial empty sella 4

Clinical Management

• Most cases of empty sella are asymptomatic and require no specific treatment beyond hormonal monitoring 2, 3
• For symptomatic patients with hormonal deficiencies, appropriate hormone replacement therapy should be instituted 7, 3
• If no hormonal alterations are detected initially, a careful reevaluation at 24-36 months is suggested due to the low risk of progression to symptomatic empty sella syndrome 2
• Visual field testing is recommended if there are any visual symptoms or concerns about increased intracranial pressure 6

Important Considerations

• Secondary adrenal insufficiency is particularly concerning in complete empty sella and should be carefully evaluated 4
• Male patients may have a higher risk of secondary hypothyroidism 4
• The discrepancy between the reported high prevalence of pituitary insufficiency (52% in some studies) and its lower prevalence in epidemiologic studies suggests possible selection bias in published literature 7
• Mental disorders, including anxiety and dysthymic disorders, have been reported in some studies of empty sella syndrome but are not typically highlighted in guidelines 8

Follow-up Recommendations

• Patients with confirmed hormonal deficiencies require ongoing endocrinological follow-up and appropriate hormone replacement therapy 3
• Asymptomatic patients with normal hormonal profiles should have repeat hormonal evaluation every 2-3 years 2
• A multidisciplinary approach involving endocrinology, neurology, and ophthalmology is recommended for proper management of symptomatic cases 3