What are the symptoms of empty sella syndrome?

Symptoms of Empty Sella Syndrome

Empty sella is most commonly an asymptomatic radiological finding discovered incidentally, but when symptoms occur (empty sella syndrome), they typically manifest as endocrine dysfunction, visual disturbances, or neurological symptoms related to increased intracranial pressure. 1, 2

Clinical Presentation Patterns

Asymptomatic Presentation (Most Common)

• The majority of patients with empty sella remain completely asymptomatic throughout their lives, with the finding discovered incidentally on imaging performed for unrelated reasons such as headache evaluation. 3, 4
• Empty sella represents only a neuroradiological finding without clinical implications in most cases, though approximately 30% of patients may demonstrate some degree of hypopituitarism upon formal testing despite lacking overt symptoms. 5

Endocrine Manifestations (When Symptomatic)

When empty sella syndrome develops, endocrine dysfunction is the most common symptomatic presentation:

• Hypopituitarism occurs in 19-40% of patients with empty sella, ranging from single hormone deficiency to panhypopituitarism. 4, 6
• Growth hormone deficiency is particularly common in pediatric populations with empty sella syndrome. 2
• Hypogonadotropic hypogonadism manifests as loss of libido, impotence in males, or amenorrhea in females. 5, 2
• Hyperprolactinemia is detected in approximately 28% of cases, potentially causing galactorrhea and menstrual irregularities. 1, 7
• Central hypothyroidism with thyroid-stimulating hormone, T3, and T4 deficiencies occurs in up to 48% of cases. 1
• Central diabetes insipidus can occur, though this association is not very rare despite being less commonly discussed. 7
• Nonspecific symptoms include fatigue, cold intolerance, and sexual dysfunction reflecting underlying hormonal deficiencies. 1

Neurological and Ophthalmological Symptoms

• Headache is frequently reported but is typically unrelated to the empty sella itself and more likely represents the reason imaging was obtained. 1
• Visual disturbances may occur when empty sella is associated with idiopathic intracranial hypertension, including visual field defects from optic chiasm compression or papilledema. 1, 6
• Symptoms of increased intracranial pressure can develop, particularly in primary empty sella associated with idiopathic intracranial hypertension. 6

Population-Specific Considerations

Adult Presentation

• In adults, empty sella is most commonly found in older, obese, hypertensive, multiparous women and is typically asymptomatic. 2
• When symptoms occur in adults, they usually have minimal impact on quality of life. 3

Pediatric Presentation

• Children with empty sella are significantly more likely to be symptomatic compared to adults, with endocrinopathies being the predominant manifestation. 2
• The incidence of empty sella in children varies from 1.2% in those without endocrine symptoms to 68% in children with known endocrinopathy. 2
• Growth hormone deficiency, hypogonadotropism, or multiple pituitary hormone deficiencies are particularly common in pediatric empty sella syndrome. 2

Key Clinical Pitfalls

• Do not attribute headache symptoms directly to empty sella without considering more common headache etiologies, as the association is typically coincidental rather than causative. 1
• Do not miss rare but important hormonal deficiencies by failing to perform appropriate screening, even in asymptomatic patients, given that 30% may have subclinical hypopituitarism. 1
• Do not overlook visual symptoms, as these may indicate coexisting idiopathic intracranial hypertension requiring urgent ophthalmologic evaluation. 1