What is the management approach for a patient with partial empty sella?

Management of Partial Empty Sella

The management of partial empty sella should include hormonal screening to rule out pituitary dysfunction, with MRI being the preferred imaging modality for diagnosis and characterization. 1, 2

Diagnostic Evaluation

• MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluating partial empty sella, as it can reliably characterize this condition even without intravenous contrast 1
• Partial empty sella is defined as cerebrospinal fluid filling <50% of the sella with pituitary height >2mm, while complete empty sella involves ≥50% filling with pituitary height <2mm 3
• Partial empty sella is often an incidental finding on imaging studies performed for unrelated reasons, such as headache evaluation 2

Hormonal Assessment

• Basic hormonal screening should be performed for all patients with partial empty sella, including:

  • Morning cortisol and ACTH to assess adrenal axis 2, 3
  • Thyroid function tests (TSH, free T4) to rule out central hypothyroidism 2, 4
  • Sex hormones (FSH, LH, estradiol in females, testosterone in males) to evaluate gonadal axis 2, 3
  • Prolactin levels 4
  • Growth hormone and IGF-1 levels 3, 4

• The prevalence of endocrine abnormalities in empty sella varies widely in studies:

  • Approximately 19-40% of patients with empty sella demonstrate some form of hypopituitarism 5
  • Secondary adrenal insufficiency and hypogonadism are more common in complete empty sella than partial empty sella 3
  • Some studies report pituitary insufficiency rates as high as 52% among patients with primary empty sella syndrome 6

Follow-up Recommendations

• If initial hormonal evaluation is normal, periodic reassessment is recommended at 24-36 months due to the low risk of progression to symptomatic empty sella syndrome 5
• For patients with hormonal deficiencies, appropriate hormone replacement therapy should be initiated based on the specific deficiencies identified 4, 7
• Regular monitoring of hormonal status is advised for patients with partial empty sella, as the condition may progress over time 5, 7

Clinical Considerations

• Most patients with partial empty sella remain asymptomatic from an endocrine perspective 5, 7
• When evaluating patients with headache and incidental partial empty sella, avoid attributing the headache directly to the empty sella without considering more common headache etiologies 2
• A multidisciplinary approach involving endocrinology, neurology, and ophthalmology may be beneficial for comprehensive management, particularly if hormonal abnormalities are detected 7

Pitfalls to Avoid

• Missing hormonal deficiencies by not performing appropriate screening, as even asymptomatic patients may have subclinical pituitary dysfunction 2, 4
• Ordering unnecessary urgent tests that won't change immediate management 2
• Failing to distinguish between partial and complete empty sella, as the risk of hormonal abnormalities differs between these conditions 3