Management of Empty Sella in an Adult with Obesity and Hypertension
Perform basic hormonal screening with thyroid function tests, morning cortisol and ACTH, sex hormones, and prolactin levels, even in the absence of symptoms, as approximately 30% of patients with empty sella demonstrate some degree of hypopituitarism. 1, 2
Initial Clinical Assessment
The finding of empty sella on CT does not require urgent workup when there are no symptoms of pituitary dysfunction or visual changes. 1, 2 However, this patient's obesity and hypertension warrant careful evaluation, as these conditions can be associated with both idiopathic intracranial hypertension and hormonal abnormalities. 3, 4
Key symptoms to actively assess include:
- Visual changes, papilledema, or diplopia suggesting increased intracranial pressure or optic chiasm compression 1, 5
- Signs of hormonal deficiencies: fatigue, cold intolerance, sexual dysfunction, menstrual irregularities 1, 2
- Headache characteristics, particularly pulsatile tinnitus or positional changes 2, 5
Recommended Hormonal Screening
Obtain the following baseline tests regardless of symptoms: 1, 2
- Thyroid-stimulating hormone, free T4 (deficiencies occur in up to 48% of cases) 1
- Morning cortisol and ACTH to assess adrenal axis 1, 2
- Sex hormones (testosterone in men, estradiol in women) 1, 5
- Prolactin levels (elevated in approximately 28% of cases) 1
- IGF-1 for growth hormone assessment 5
The rationale for screening asymptomatic patients is compelling: pooled analysis shows 52% of patients with primary empty sella have pituitary insufficiency, though many remain clinically silent. 6 More recent data confirms endocrine disorders in 19-40% of patients. 7
Imaging Considerations
MRI with high-resolution pituitary protocols is the preferred imaging modality if further characterization is needed. 8, 1 However, if CT already confirms empty sella without other concerning features, no additional urgent imaging is required. 1
MRI without contrast provides adequate diagnostic detail, though contrast is preferred for detecting small pituitary lesions if hormonal abnormalities are found. 8, 1 Consider MR venography if signs of idiopathic intracranial hypertension are present (headache, papilledema, pulsatile tinnitus), particularly given the patient's obesity, which is a risk factor. 5, 3
Specialist Referrals
Endocrinology referral is indicated if: 1, 5
- Any hormonal abnormalities are detected on screening
- Symptoms suggestive of pituitary dysfunction develop
Ophthalmology evaluation is necessary if: 1, 2
- Visual symptoms are present
- Papilledema or signs of increased intracranial pressure are noted
- Optic chiasm compression is seen on imaging
Neurology consultation should be considered if: 5
- Signs of idiopathic intracranial hypertension are present
- Progressive or severe headaches develop
Follow-Up Strategy
If initial hormonal screening is normal and no symptoms are present, careful reevaluation at 24-36 months is suggested given the low risk of progression to empty sella syndrome. 7 However, patients should be counseled to report new symptoms of hormonal deficiency or visual changes promptly. 1, 3
Critical Pitfalls to Avoid
Do not attribute unrelated symptoms (such as headache) directly to the empty sella without considering more common etiologies. 1, 2 Primary headache disorders like migraine or tension-type headache are far more prevalent. 5
Do not skip hormonal screening based on absence of symptoms. 1, 6 The discrepancy between high prevalence of hormonal dysfunction in empty sella patients and low clinical recognition suggests many cases are missed. 6
Do not miss signs of idiopathic intracranial hypertension, particularly in obese patients with empty sella, as this association is well-established and can lead to permanent visual loss if untreated. 3, 4
Be aware that exogenous steroid use can cause or worsen empty sella and intracranial hypertension. 4 Document any history of glucocorticoid therapy in this hypertensive patient.