What is the management of empty sella syndrome?

Management of Empty Sella Syndrome

The management of empty sella syndrome should focus on hormonal evaluation, with MRI being the preferred diagnostic imaging modality and treatment directed at addressing any identified hormonal deficiencies. 1, 2

Diagnostic Approach

• MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluation of empty sella, which can be well characterized even without IV contrast 1
• Basic hormonal screening should be performed for all patients with empty sella, regardless of whether it's partial or complete, as affected-axis rates often exceed 10% and may reach 50% 3, 4
• Recommended hormonal evaluation includes:
  • Morning cortisol and ACTH (adrenal axis)
  • Thyroid function tests (TSH, free T4)
  • Sex hormones (FSH, LH, estradiol in females, testosterone in males)
  • Prolactin
  • Growth hormone and IGF-1 2, 3

Clinical Assessment

• Empty sella is often an incidental finding, with approximately 30% of patients demonstrating some degree of hypopituitarism upon testing 1, 5
• The prevalence of pituitary insufficiency in patients with primary empty sella syndrome ranges from 19% to 52% according to various studies 5, 4
• Complete empty sella (≥50% CSF filling, pituitary <2 mm) is associated with a higher risk of secondary adrenal insufficiency and hypogonadism compared to partial empty sella (<50% filling, pituitary >2 mm) 3

Management Strategy

• For asymptomatic patients with normal hormonal function:

  • Conservative management with periodic follow-up
  • Reassessment of hormonal function at 24-36 months due to low risk of progression 4

• For patients with hormonal deficiencies:

  • Appropriate hormone replacement therapy based on identified deficiencies
  • Secondary adrenal insufficiency (present in up to 62.5% of cases): hydrocortisone replacement 3, 6
  • Secondary hypothyroidism (present in up to 50% of cases): levothyroxine replacement 6
  • Hypogonadism (present in up to 18.75% of cases): sex hormone replacement 6
  • Growth hormone deficiency (present in up to 12.5% of cases): consider GH replacement 6
  • Hyperprolactinemia (present in up to 18.75% of cases): dopamine agonists if symptomatic 6

Special Considerations

• Empty sella syndrome requires a multidisciplinary approach involving endocrinology, neurology, and ophthalmology, especially when associated with idiopathic intracranial hypertension 7
• Male patients should be monitored closely for secondary hypothyroidism, which appears to be more common in this population 3
• Patients with complete empty sella require more vigilant monitoring for hormonal deficiencies, particularly adrenal insufficiency and hypogonadism 3

Pitfalls to Avoid

• Not performing hormonal testing for all empty sella patients, as hormonal deficiencies are common and may be clinically significant 3, 5
• Attributing unrelated symptoms directly to empty sella without considering more common etiologies 2
• Missing rare but important hormonal deficiencies by not performing comprehensive endocrine evaluation 2
• Unnecessary surgical intervention for stable, asymptomatic empty sella 8