What are the symptoms and treatment options for conditions affecting the sella turcica of the brain?

Sellar Pathology: Symptoms and Treatment

Diagnostic Imaging Approach

MRI of the sella using high-resolution pituitary protocols is the mandatory first-line imaging modality for evaluating any suspected sellar pathology, as CT is fundamentally inadequate for characterizing lesions in this region. 1, 2

Why MRI is Essential

• MRI directly visualizes the pituitary gland, infundibulum, optic chiasm, and vascular structures with superior tissue characterization compared to CT 1, 2
• High-resolution pituitary protocols can detect microadenomas (<10 mm) and characterize empty sella syndrome even without IV contrast 1, 2
• CT should only be used for detecting bone-destructive lesions of the skull base or for preoperative assessment of sphenoid sinus anatomy prior to trans-sphenoidal surgery 1

MRI Protocol Specifications

• Include high-resolution pituitary sequences with thin-section acquisition and multiplanar reformatting 1
• Obtain pre- and post-contrast T1-weighted sequences and coronal fat-saturated T2-weighted sequences 2
• Add MR venography (MRV) if pseudotumor cerebri is suspected 2

Clinical Symptoms by Pathology Type

Hypofunctioning Pituitary (Hypopituitarism)

• Fatigue, cold intolerance, weight changes suggesting hypothyroidism 3
• Loss of libido, impotence, sexual dysfunction indicating hypogonadotropic hypogonadism 1, 3
• Growth deceleration in children or growth hormone deficiency in adults 1
• Symptoms may be caused by mass effect from extrinsic lesions (craniopharyngioma, Rathke cleft cyst, meningioma, germ-line tumors) or intrinsic pituitary abnormalities 1

Hyperfunctioning Pituitary Adenomas

• Prolactinoma: Galactorrhea, amenorrhea, infertility in women; loss of libido and impotence in men 1
• Acromegaly/Gigantism: Progressive enlargement of hands, feet, facial features from growth hormone excess 1
• Cushing Syndrome: Weight gain, moon facies, striae from ACTH excess 1
• Hyperthyroidism: From TSH-secreting adenomas (rare) 1

Mass Effect Symptoms (Any Sellar Lesion)

• Headache patterns suggesting elevated intracranial pressure 2
• Visual field defects, declining visual acuity from optic chiasm compression 1, 2
• Papilledema and pulsatile tinnitus indicating elevated ICP 2
• Visual field impairment is a known complication of macroprolactinoma, though effective treatment may paradoxically cause secondary deterioration from chiasmal herniation into the partially empty sella 4

Empty Sella Syndrome

• Often asymptomatic and discovered incidentally 1, 3
• Approximately 30% of patients demonstrate some hypopituitarism upon testing despite lack of symptoms 1, 3
• May present with headache unrelated to the empty sella itself 3

Hormonal Screening Protocol

Obtain comprehensive hormonal screening in all patients with sellar pathology, as hormonal deficiencies may be present even in asymptomatic individuals. 2, 3

Essential Laboratory Tests

• Thyroid function: TSH, free T4, free T3 (deficiencies seen in up to 48% of empty sella cases) 3
• Adrenal axis: Morning cortisol and ACTH 2, 3
• Sex hormones: Testosterone in men, estradiol and FSH/LH in women 2, 3
• Prolactin levels (elevated in approximately 28% of empty sella cases) 3
• Growth hormone/IGF-1 if acromegaly suspected 2

Treatment Approach by Pathology

Pituitary Adenomas

Refer to endocrinology for all cases of pituitary adenoma, and consider neurosurgery referral for macroadenomas or symptomatic microadenomas. 2

Medical Management

• Prolactinomas may respond to dopamine agonists (bromocriptine, cabergoline) 1
• Critical bromocriptine precaution: Monitor for intense urges to gamble, increased sexual urges, or uncontrolled spending; consider dose reduction or discontinuation if these develop 4
• Monitor visual fields in patients with macroprolactinoma for early recognition of secondary field loss from chiasmal herniation 4

Surgical Management

• Trans-sphenoidal endoscopic resection is the primary surgical approach 1, 5
• Preoperative CT with thin-section acquisition aids intraoperative navigation and provides osseous detail of sphenoid sinus anatomy 1
• Identifying invasion of suprasellar cistern, skull base, or cavernous sinuses is critical for surgical planning 5

Empty Sella Syndrome

• Refer to endocrinology if hormonal abnormalities detected on screening 2, 3
• Consider lumbar puncture if elevated ICP suspected based on clinical symptoms 2
• No urgent intervention needed for asymptomatic incidental findings 3

Pituitary Hypoplasia

• Congenital hypopituitarism requires immediate attention to prevent cognitive impairment and metabolic derangements 6
• Acquired causes include surgical hypophysectomy, cranial irradiation, traumatic brain injury, and chronic systemic diseases 6
• MRI with high-resolution pituitary protocols is the gold standard for evaluating pituitary size 6

Urgent Evaluation Criteria

Expedite MRI and obtain urgent ophthalmology referral if any of the following are present: 2

• Visual field defects or declining visual acuity 2
• Papilledema 2
• Symptoms suggesting acute pituitary apoplexy (sudden severe headache, visual changes, altered consciousness) 2

Special Vascular Considerations

• CTA or MRA indicated when vascular lesions such as aneurysm suspected, though these rarely cause hypothalamic-pituitary axis symptoms 1
• Preoperative detection of coexisting intrasellar aneurysm is mandatory to avoid life-threatening hemorrhagic complications during adenoma resection 7

Common Pitfalls to Avoid

• Do not attribute headache symptoms directly to empty sella without considering more common headache etiologies 3
• Do not use CT as first-line imaging for sellar pathology evaluation, as it is insensitive compared to MRI 1
• Do not miss hormonal screening even in asymptomatic patients, as 30% with empty sella have hypopituitarism 1, 3
• Monitor for tumor expansion during bromocriptine therapy, as possible tumor expansion has been reported in a few patients 4
• Discontinue bromocriptine immediately once pregnancy is established, and monitor closely throughout pregnancy for signs of tumor enlargement 4
• Recognize that visual field improvement may require bromocriptine dose reduction in cases of chiasmal herniation into partially empty sella, despite some tumor re-expansion 4