What to do if a computed tomography (CT) scan shows a partial empty sella?

Management of Partial Empty Sella on CT

All patients with a partial empty sella on CT require comprehensive hormonal screening and should undergo MRI with high-resolution pituitary protocols for definitive characterization, regardless of symptoms. 1

Immediate Next Steps

Obtain MRI for Definitive Evaluation

• CT is fundamentally inadequate for evaluating sellar pathology—MRI using high-resolution pituitary protocols is the gold standard and must be obtained. 2, 3
• MRI can directly visualize the pituitary gland, infundibulum, and optic chiasm with superior tissue characterization even without IV contrast. 2, 3
• The MRI protocol should include high-resolution pituitary sequences, pre- and post-contrast T1-weighted sequences, and coronal fat-saturated T2-weighted sequences. 3

Perform Mandatory Hormonal Screening

• All patients require comprehensive hormonal screening regardless of symptoms, as hormonal deficiencies occur in 30-48% of cases. 1, 4
• The hormonal panel must include:
  • Thyroid function tests (TSH, free T4, T3)—deficiencies seen in up to 48% of cases 5
  • Morning cortisol and ACTH for adrenal axis assessment 5
  • Sex hormones (testosterone in males, estradiol/FSH/LH in females) 5
  • Prolactin levels—elevated in approximately 28% of cases 5, 4
  • IGF-1 and growth hormone axis evaluation 1

Clinical Assessment for Urgent Features

Screen for Red Flag Symptoms Requiring Expedited Evaluation

• Visual changes, visual field defects, or declining visual acuity indicate potential optic chiasm compression requiring urgent ophthalmology referral and expedited MRI. 1, 3
• Headache with papilledema, pulsatile tinnitus, or features of elevated intracranial pressure may indicate idiopathic intracranial hypertension (IIH), particularly in the appropriate demographic. 1, 3
• CSF rhinorrhea requires urgent neurosurgical evaluation. 1
• Signs of hormonal deficiencies including fatigue, cold intolerance, sexual dysfunction, or features of hypopituitarism warrant endocrine evaluation. 5

Specialist Referrals

Endocrinology Referral

• Refer to endocrinology if any hormonal abnormalities are detected on screening or if symptoms suggest pituitary dysfunction. 1, 5
• Even asymptomatic patients with documented hormonal deficiencies require endocrine management for hormone replacement therapy. 4

Ophthalmology Referral

• Refer to ophthalmology if visual symptoms are present, concerns about increased intracranial pressure exist, or optic chiasm compression is noted on imaging. 1, 5

Neurosurgery Consideration

• Neurosurgery referral is indicated for symptomatic intracranial hypertension requiring CSF shunting procedures or documented CSF rhinorrhea. 4

Special Consideration: Idiopathic Intracranial Hypertension

• Partially empty sella is a typical neuroimaging feature of raised intracranial pressure and may indicate underlying IIH, particularly in patients with headache and papilledema. 1
• If IIH is suspected or confirmed, weight loss is the primary treatment with referral to weight management programs; surgical CSF diversion is reserved for imminent visual loss. 1
• Consider MR venography (MRV) if pseudotumor cerebri is suspected. 3

Critical Pitfalls to Avoid

Do Not Attribute Headache to Empty Sella

• Empty sella is usually an incidental finding unrelated to headache symptoms—do not attribute headache directly to the empty sella. 1, 5
• Evaluate for more common headache etiologies rather than assuming causation. 5

Do Not Overlook IIH

• Do not miss IIH in patients with headache and partially empty sella, as it represents a distinct clinical entity requiring specific management. 1

Do Not Skip Hormonal Screening

• Missing hormonal deficiencies by not performing appropriate screening is a critical error, as affected-axis rates often exceed 10% and may reach 50%. 1
• Even patients with "partial" empty sella can have global anterior hypopituitarism or isolated hormone deficiencies. 4

Do Not Rely on CT Alone

• CT is insensitive and nonspecific for evaluating sellar pathology and cannot adequately characterize pituitary tissue or detect microadenomas. 2, 3

Understanding the Clinical Context

• Approximately 39% of control subjects without pituitary disorders can have moderate empty sella on imaging, but this does not negate the need for hormonal screening when identified. 6
• The female-to-male ratio is over 4:1, with mean age at diagnosis around 52 years and mean BMI of 27.3 kg/m². 4
• Hyperprolactinemia is the most common endocrine abnormality (10.3% of patients), followed by isolated GH deficiency and global anterior hypopituitarism. 4