What is empty sella syndrome and how does it present in middle-aged, obese women with hypertension?

Empty Sella Syndrome: Definition and Clinical Presentation

Empty sella syndrome (ESS) is characterized by herniation of cerebrospinal fluid into the sella turcica with compression and flattening of the pituitary gland, presenting most commonly as an incidental radiographic finding in middle-aged, obese women with hypertension—a demographic particularly at risk for associated idiopathic intracranial hypertension. 1, 2

Pathophysiology and Classification

Empty sella occurs when the subarachnoid space herniates into the sella turcica, causing variable degrees of pituitary gland compression. 3 The condition divides into two distinct categories:

• Primary empty sella: Idiopathic condition with no prior pituitary pathology, often associated with idiopathic intracranial hypertension (IIH), particularly in obese women with hypertension 1, 3
• Secondary empty sella: Results from prior pituitary surgery, radiation, tumor necrosis, autoimmune hypophysitis, trauma, or infectious processes 4, 3

The classic demographic—middle-aged, obese, hypertensive women—represents the typical IIH patient population, where partially empty sella serves as a neuroimaging marker of chronically elevated intracranial pressure. 1, 2

Clinical Presentation Spectrum

Asymptomatic Presentation (Most Common)

• The majority of empty sella cases remain completely asymptomatic and are discovered incidentally during imaging for unrelated conditions such as headache evaluation. 1, 5
• Approximately 70% of patients never develop symptoms requiring intervention 1, 2

Endocrine Manifestations

When symptomatic, endocrine dysfunction dominates the clinical picture:

• Hypopituitarism occurs in approximately 30% of patients with empty sella, though rates of affected hormonal axes can reach 48-50% when systematically screened 1, 2, 6
• Central hypothyroidism presents with fatigue, cold intolerance, and weight gain 6, 7
• Hypogonadotropic hypogonadism manifests as loss of libido, impotence in males, and menstrual irregularities in females 1
• Growth hormone deficiency causes fatigue and decreased exercise tolerance 6
• Hyperprolactinemia occurs in approximately 28% of cases 6
• Adrenal insufficiency presents with weakness, fatiguability, and potentially life-threatening hyponatremia 7
• Rare presentations include sinus bradycardia from central hypothyroidism 8

Neurological and Ophthalmological Features

In the context of associated IIH (particularly relevant for obese, hypertensive women):

• Severe headaches with features of increased intracranial pressure (worse with Valsalva, morning predominance) 1, 2
• Visual disturbances including transient visual obscurations, diplopia, and progressive visual field defects 2, 3
• Papilledema on fundoscopic examination 1, 2
• CSF rhinorrhea in rare cases 1, 4

Critical Diagnostic Pitfall

Do not attribute headache symptoms directly to the empty sella finding itself—empty sella is typically an incidental finding unrelated to headache, and the headache requires separate evaluation for primary headache disorders or, crucially in this demographic, for IIH. 2, 6 The partially empty sella in an obese, hypertensive woman with headache should raise immediate suspicion for IIH rather than being dismissed as an incidental finding. 1, 2

Mandatory Evaluation Algorithm

Hormonal Screening (Required for ALL Patients)

All patients with empty sella—even if completely asymptomatic—require comprehensive hormonal screening, as hormonal deficiencies frequently occur without obvious clinical manifestations. 2, 6 The panel must include:

• Thyroid function: TSH, free T4, free T3 6, 9
• Adrenal axis: morning cortisol and ACTH 6, 9
• Gonadal axis: testosterone (males), estradiol and LH/FSH (females) 6, 9
• Prolactin level 6, 9
• IGF-1 for growth hormone axis 9

Ophthalmological Assessment

Ophthalmology referral is mandatory if:

• Visual symptoms are present 2, 6
• Papilledema is suspected clinically 2, 5
• Patient fits IIH demographic (obese woman with headache) 1, 2
• Optic chiasm compression noted on imaging 6, 9

Imaging Confirmation

• MRI with high-resolution pituitary protocols is the gold standard for diagnosis and can confirm empty sella even without IV contrast 1, 6, 9
• CT is insensitive for pituitary pathology and should not be used as first-line imaging 1
• MR venography should be added if IIH is suspected to evaluate for venous sinus stenosis 9

Management Approach for the Obese, Hypertensive Woman

If Associated with IIH

Weight loss is the primary treatment for IIH-associated empty sella, with referral to structured weight management programs. 2 Surgical CSF diversion is reserved only for imminent visual loss. 2

If Hormonal Deficiencies Detected

• Endocrinology referral for hormone replacement therapy 2, 6, 9
• Treatment is straightforward and lifesaving when deficiencies are identified 7

If Truly Asymptomatic

• No urgent intervention required beyond initial hormonal screening and ophthalmological assessment 2, 6
• Avoid ordering unnecessary repeat imaging or invasive tests that won't change management 2, 6