What is the management approach for a partially empty sella?

Management of Partially Empty Sella

A partially empty sella is typically an incidental finding that requires hormonal screening but not urgent intervention unless there are symptoms of pituitary dysfunction, visual changes, or signs of increased intracranial pressure. 1

Initial Clinical Assessment

The management approach depends entirely on whether the patient has symptoms or if this is an incidental finding:

• Asymptomatic incidental finding: Approximately 30% of patients with empty sella demonstrate some degree of hypopituitarism upon testing, though most remain asymptomatic and require no urgent workup. 2, 1

• Key symptoms requiring urgent evaluation: Visual changes, signs of hormonal deficiencies (fatigue, cold intolerance, sexual dysfunction), headache with features of increased intracranial pressure, or CSF rhinorrhea. 1, 3

• Association with idiopathic intracranial hypertension (IIH): Partially empty sella is listed as a typical neuroimaging feature of raised intracranial pressure and may indicate underlying IIH, particularly in patients with headache and papilledema. 2

Mandatory Hormonal Screening

All patients with partially empty sella should undergo comprehensive hormonal screening regardless of symptoms, as affected-axis rates often exceed 10% and may reach 50%:

• Complete PES (≥50% CSF filling) carries higher risk: Secondary adrenal insufficiency and secondary hypogonadism are significantly more common in complete versus partial empty sella, with two or more affected axes more likely in complete PES. 4

• Recommended hormonal panel: 1, 4

  • Thyroid function: TSH, free T4 (deficiencies seen in up to 48% of cases)
  • Adrenal axis: Morning cortisol and ACTH
  • Gonadal axis: FSH, LH, estradiol (females), total testosterone (males)
  • Prolactin (elevated in approximately 28% of cases)
  • Growth hormone axis: IGF-1

• Gender-specific consideration: Secondary hypothyroidism is significantly more common among males with empty sella. 4

Imaging Considerations

• MRI is the preferred modality: High-resolution pituitary protocols confirm the diagnosis and exclude other pathology, with no additional urgent imaging needed if MRI already demonstrates partially empty sella without concerning features. 2, 1

• CT has limited utility: CT can detect bone-destructive lesions and larger masses but is insensitive compared to MRI for pituitary pathology. 2

Specialist Referrals

• Endocrinology referral indicated if: Any hormonal abnormalities detected on screening, or symptoms suggestive of pituitary dysfunction (fatigue, cold intolerance, sexual dysfunction). 1

• Ophthalmology referral indicated if: Visual symptoms present, concerns about increased intracranial pressure, or optic chiasm compression noted on imaging. 1

• Neurology/neurosurgery referral indicated if: Signs of IIH (papilledema, visual field defects, severe headache), CSF rhinorrhea, or severe increased intracranial pressure. 3

Treatment Approach

Most cases require no specific treatment beyond hormonal replacement if deficiencies are identified:

• Conservative management: Non-symptomatic cases require no treatment but need periodic follow-up with repeat hormonal assessment. 3, 5

• Surgical indications are rare: CSF rhinorrhea, progressive visual disturbance despite medical management, or severe increased intracranial pressure unresponsive to medical therapy. 3, 6

• If associated with IIH: Weight loss is the primary treatment (up to 15% weight loss may be required for remission), with referral to weight management programs; surgical CSF diversion (ventriculoperitoneal shunt preferred) reserved for imminent visual loss. 2

Critical Pitfalls to Avoid

• Do not attribute headache directly to empty sella: Consider more common headache etiologies first, as empty sella is usually an incidental finding unrelated to headache symptoms. 1

• Do not skip hormonal screening: Even in asymptomatic patients, hormonal deficiencies are common and may be clinically significant, particularly in complete empty sella. 4, 5

• Do not overlook IIH: In patients with headache and partially empty sella, assess for papilledema and other signs of raised intracranial pressure, as this represents a distinct clinical entity requiring specific management. 2

• Do not order unnecessary urgent tests: Avoid imaging studies or interventions that won't change immediate management in asymptomatic patients with confirmed partially empty sella on MRI. 1