What is the meaning of empty sella turcica (empty sella syndrome) in a middle-aged woman?

Empty Sella Turcica: Definition and Clinical Significance

Empty sella turcica is a radiographic finding where cerebrospinal fluid herniates into the sella turcica through an incompetent diaphragma sellae, causing compression and flattening of the pituitary gland. 1, 2

Anatomic and Pathophysiologic Understanding

• The condition represents herniation of the subarachnoid space and arachnoid membrane into the sella turcica, which may be completely or partially filled with cerebrospinal fluid 1, 2
• An empty sella of normal size is a frequent and likely normal finding in unselected autopsy series, but clinically detected cases usually show an enlarged sella 3
• Primary empty sella occurs without any history of pituitary surgery, radiation, or known pituitary pathology, while secondary empty sella develops after treatment of pituitary tumors, spontaneous tumor necrosis, pituitary infections, autoimmune disease, or trauma 2

Epidemiology and Clinical Context in Middle-Aged Women

• Primary empty sella predominantly affects obese, middle-aged, often multiparous women 4
• The condition is frequently discovered incidentally during imaging performed for unrelated reasons, particularly headache evaluation 1, 5
• Standard skull X-rays show poor sensitivity for detecting empty sella, with negative findings in approximately half of cases 4

Clinical Significance and Associated Conditions

Hormonal Dysfunction

• Approximately 30% of patients with empty sella demonstrate some degree of hypopituitarism upon testing, though most remain asymptomatic 1, 6
• Thyroid-stimulating hormone, T3, and T4 deficiencies occur in up to 48% of cases 1
• Elevated prolactin levels are found in approximately 28% of cases 1
• All patients with empty sella should undergo comprehensive hormonal screening regardless of symptoms, as affected-axis rates often exceed 10% and may reach 50% 6

Association with Idiopathic Intracranial Hypertension

• Empty sella or partially empty sella is a typical neuroimaging feature of raised intracranial pressure and may indicate underlying idiopathic intracranial hypertension (IIH), particularly in patients with headache and papilledema 6, 7
• Headache occurs in nearly 90% of patients with IIH, typically holocephalic or unilateral throbbing, worse in the morning and improving with upright posture 7
• Other IIH symptoms include visual disturbances, pulsatile tinnitus, and diplopia (often horizontal due to sixth nerve palsy) 7

Rare but Important Complications

• Visual field defects may occur due to optic chiasm compression 3, 2
• CSF rhinorrhea can develop in some cases 3, 2

Mandatory Diagnostic Workup

Imaging

• MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality and can confirm the diagnosis even without IV contrast 1, 6
• CT has limited utility and is insensitive compared to MRI for detecting pituitary pathology 6

Hormonal Screening (Required for All Patients)

• Basic hormonal screening must include thyroid function tests (TSH, T3, T4), morning cortisol and ACTH, sex hormones, prolactin, and growth hormone axis evaluation 1, 6
• This screening is mandatory regardless of symptoms, given the high prevalence of hormonal abnormalities 6, 5

Ophthalmologic Evaluation

• All patients with empty sella and unidentified underlying etiology should receive a formal ophthalmology referral for assessment of papilledema and visual field testing 6, 5
• This is particularly critical if visual symptoms are present or if concerns about increased intracranial pressure exist 6

Specialist Referral Indications

Endocrinology Referral

• Refer if any hormonal abnormalities are detected on screening 1, 6
• Refer if symptoms suggestive of pituitary dysfunction exist (fatigue, cold intolerance, sexual dysfunction) 1, 6

Ophthalmology Referral

• Refer if visual symptoms are present, papilledema is detected, or optic chiasm compression is noted on imaging 1, 6
• Refer if concerns about increased intracranial pressure exist 6

Neurosurgery Referral

• Consider if medical therapy fails in cases of IIH with declining visual function 7
• Surgical CSF diversion is reserved for imminent visual loss 6

Management Approach Based on Clinical Presentation

Asymptomatic Incidental Finding

• No urgent workup is necessary when there is no history or symptoms of pituitary dysfunction 1
• Perform mandatory hormonal screening and ophthalmology referral as outlined above 6, 5
• No additional urgent imaging is needed if MRI already confirms empty sella without other concerning features 1, 6

Associated with IIH

• Weight loss is the primary treatment for IIH-associated empty sella, with referral to weight management programs 6, 7
• Acetazolamide is recommended for medical management 7
• Surgical intervention is reserved for cases with imminent visual loss 6, 7

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 1, 6
• Do not overlook IIH in patients with headache and partially empty sella, as it represents a distinct clinical entity requiring specific management 6
• Do not skip hormonal screening even in asymptomatic patients, as hormonal deficiencies are common and may be clinically significant 6, 5
• Do not assume normal neurological examination excludes significant pathology in the setting of progressive symptoms 7
• Do not order unnecessary urgent tests or interventions that won't change immediate management in asymptomatic patients with confirmed empty sella on MRI 1, 6