From the Guidelines
An enlarged primary empty sella on Brian's MRI indicates a condition that may require endocrine evaluation and monitoring, despite often being incidental and not necessarily requiring treatment if there are no associated symptoms or hormonal abnormalities. This finding is characterized by the pituitary gland appearing flattened or smaller than normal within an enlarged sella turcica, with the space being filled with cerebrospinal fluid 1. The condition can sometimes be associated with hormonal deficiencies, and approximately 30% of patients may demonstrate some hypopituitarism upon testing 2, 3.
Key Considerations
- Brian should undergo endocrine evaluation to check pituitary function, including tests for thyroid hormones, cortisol, growth hormone, and sex hormones.
- Visual field testing is also recommended since an enlarged sella can occasionally put pressure on the optic chiasm.
- Primary empty sella syndrome differs from secondary empty sella, which occurs after surgery, radiation, or infarction of a pituitary tumor.
- The condition is more common in middle-aged, overweight women and may be related to increased intracranial pressure that compresses the pituitary gland over time.
Diagnostic Approach
- MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluation of the pituitary and sellar regions 1.
- The addition of IV contrast is preferred for the assessment of pituitary lesions; however, a noncontrast MRI also provides diagnostic detail 4.
- An empty sella is well characterized on MRI, even without IV contrast 1.
Management and Monitoring
- Most cases remain stable and don't progress to cause significant health problems, but regular monitoring is important to detect any developing hormonal or visual issues.
- The management approach should prioritize minimizing morbidity, mortality, and optimizing quality of life, considering the potential risks and benefits of treatment and monitoring strategies 2, 3, 1, 4.
From the Research
Definition and Causes of Empty Sella
- An empty sella (ES) develops when cerebrospinal fluid (CSF) fills the sella turcica and compresses pituitary tissue until it lines the sellar floor and walls 5.
- Primary ES occurs when CSF enters the sella through a rent in the sellar diaphragm that may or may not be associated with increased intracranial pressure 5.
- Secondary ES is a result of an injury to the pituitary itself (e.g., pituitary apoplexy) or the consequence of surgical or radiation treatment 5.
Symptoms and Diagnosis
- Primary empty sella is usually free from clinical symptoms but sometimes associated with headache, obesity, visual disturbance, non-traumatic CSF rhinorrhea, and pituitary insufficiency 6.
- Magnetic resonance imaging (MRI) is useful in diagnosing empty sella 6.
- The incidence of empty sella is about 12% when it comes to neuroimaging, while in clinical practice it can reach 35% 7.
- Endocrine pituitary disorders, defined as at least one hormone deficit, were reported in 19% to 40% of patients 7.
Treatment and Management
- Treatment of ES includes replacement of hormone deficiencies and occasionally surgical measures to relieve obstructive intracranial lesions 5.
- CSF rhinorrhea, visual disturbance, and severe increased intracranial pressure are the indications for surgical treatment 6.
- Non-symptomatic cases require no treatment but periodical follow-up is necessary 6.
- A multidisciplinary approach, with the integration of endocrine, neurologic, and ophthalmologic expertise, is strongly advocated and recommended for a properly diagnosis, management, treatment, and follow-up of PES syndrome and all of the related abnormalities 8.