Clinical Significance of Empty Sella on MRI
An empty sella seen on MRI is usually an incidental finding of no clinical significance, but approximately 30% of patients may demonstrate some degree of hypopituitarism upon testing, warranting basic hormonal screening in all cases. 1, 2, 3
Understanding the Finding
Empty sella represents herniation of cerebrospinal fluid into the sella turcica through a developmental or acquired dehiscence of the diaphragm sella, resulting in compression and flattening of the pituitary gland. 1
Diagnostic Confirmation
- MRI is the gold standard for characterizing empty sella and can confirm the diagnosis even without IV contrast. 1
- The finding is increasingly common with routine neuroimaging, with an incidence of approximately 12% on neuroimaging studies and up to 35% in clinical practice. 4
- Sellar emptiness increases significantly with age and is more prominent in women, making it a common normal anatomical variation in many cases. 5
Clinical Assessment Required
Mandatory Hormonal Screening
All patients with empty sella should undergo comprehensive hormonal screening regardless of symptoms, as endocrine pituitary disorders occur in 19-40% of patients. 3, 4
The hormonal panel must include: 2, 3
- Thyroid function tests (TSH, free T4) - deficiencies seen in up to 48% of cases
- Morning cortisol and ACTH (adrenal axis assessment)
- Sex hormones (gonadal axis)
- Prolactin levels - elevated in approximately 28% of cases
- Growth hormone axis evaluation
Symptoms Requiring Urgent Evaluation
Key red flag symptoms that warrant immediate specialist referral include: 2, 3
- Visual changes or visual field defects
- Signs of hormonal deficiencies (fatigue, cold intolerance, sexual dysfunction)
- Headache with features of increased intracranial pressure
- CSF rhinorrhea
- Papilledema
Association with Idiopathic Intracranial Hypertension
Partially empty sella is a typical neuroimaging feature of raised intracranial pressure and may indicate underlying idiopathic intracranial hypertension (IIH), particularly in patients presenting with headache and papilledema. 3
- This represents a distinct clinical entity requiring specific management beyond simple empty sella. 3
- Weight loss is the primary treatment for IIH-associated empty sella, with surgical CSF diversion reserved for imminent visual loss. 3
Specialist Referrals
Endocrinology Referral Indicated When:
- Any hormonal abnormalities are detected on screening 2, 3
- Symptoms suggestive of pituitary dysfunction are present 2, 3
Ophthalmology Referral Indicated When:
- Visual symptoms are present 2, 3
- Concerns about increased intracranial pressure exist 2, 3
- Optic chiasm compression is noted on imaging 2, 3
- Papilledema is suspected 3
Follow-Up Strategy
If no hormonal alterations are detected and the patient remains asymptomatic, careful reevaluation at 24-36 months is suggested given the low risk of progression to empty sella syndrome. 4
- Periodic follow-up is necessary even in asymptomatic cases to monitor for development of hypopituitarism, CSF rhinorrhea, visual disturbance, or increased intracranial pressure. 6, 7
- The majority of patients never become symptomatic, and if symptoms do arise, they usually have little impact on quality of life. 8
Critical Pitfalls to Avoid
Do not attribute headache symptoms directly to empty sella without considering more common headache etiologies, as empty sella is usually an incidental finding unrelated to headache. 2, 3
Do not overlook IIH in patients with headache and partially empty sella, as this represents a distinct clinical entity requiring specific management. 3
Do not skip hormonal screening even in asymptomatic patients, as affected-axis rates often exceed 10% and may reach 50%. 3
Do not order unnecessary urgent imaging or interventions in asymptomatic patients with confirmed empty sella on MRI, as these won't change immediate management. 2, 3
Do not miss rare but important hormonal deficiencies by failing to perform appropriate comprehensive screening. 2