Signs and Symptoms of Sellar Masses
Sellar masses present with three cardinal symptom categories: hormonal dysfunction (most commonly secondary hormone deficiencies or hyperprolactinemia), mass effect symptoms (particularly visual field defects and headache), or are discovered incidentally on imaging performed for unrelated reasons. 1, 2
Clinical Presentation Patterns
Hormonal Manifestations
- Secondary hormone deficiencies are the most common presenting feature in clinically manifesting sellar masses, occurring in 29.7% of symptomatic patients 1
- Hyperprolactinemia is a frequent indication prompting pituitary imaging, particularly in patients with prolactinomas (the most common functioning adenoma) 2
- Hypogonadism commonly triggers evaluation, with suppressed luteinizing hormone, follicle-stimulating hormone, and sex hormones 2, 3
- Diabetes insipidus may occur with sellar masses affecting the hypothalamic-pituitary axis, though it is uncommon in nonfunctioning adenomas (only 7% at presentation) 4, 5
- Hypopituitarism affects 37-85% of patients with nonfunctioning pituitary adenomas, with the GH axis most commonly affected (61-100%), followed by gonadal (36-96%), adrenal (17-62%), and thyroid axes (8-81%) 5
Mass Effect Symptoms
- Visual field defects occur in 24.2% of clinically manifesting sellar masses and 29.3% of incidentally discovered masses, with bitemporal hemianopsia being characteristic of optic chiasm compression 1, 6
- Headache is a prominent presenting symptom, particularly when acute or rapidly progressive 3
- Diplopia and eye pain suggest cavernous sinus involvement or cranial nerve compression 3
- Acute neurological symptoms may indicate pituitary apoplexy with sudden hemorrhage into the adenoma 4, 7
Pituitary Apoplexy (Specific Context for Subarachnoid Hemorrhage History)
- Sudden severe headache with acute onset is the hallmark presentation of pituitary apoplexy 4, 7
- Oculomotor palsies frequently accompany apoplexy due to cavernous sinus involvement 4
- Hemorrhage from pituitary adenomas can manifest as diffuse subarachnoid hemorrhage, simulating rupture of an anterior cerebral artery aneurysm on CT imaging 7
- Tumor enlargement, sellar expansion, and intratumoral hemorrhage are characteristic findings on MRI, with T1 signal hyperintensity, low T2 signal, or hemorrhage fluid levels within the pituitary gland 4
Incidental Presentations
- Neurological complaints (34.2%) are the most common reason for imaging that reveals incidental pituitary masses 1
- Approximately 47% of pituitary MRI scans performed yield no visible lesion, highlighting the frequency of normal findings 2
- Incidentally discovered masses are more likely to be macroadenomas (70.7% vs 49.9% in symptomatic masses) 1
Red Flag Symptoms Requiring Urgent Evaluation
- Rapidly progressive headache with subsequent visual impairment in patients with large sellar masses may indicate aggressive malignancy such as atypical teratoid/rhabdoid tumor 3
- Acute bilateral blindness can develop post-operatively or from rapid tumor expansion 3
- Signs of increased intracranial pressure including papilledema warrant immediate assessment 8
Common Pitfalls
- Empty sella findings (approximately 30% demonstrate some hypopituitarism) should not be dismissed without hormonal screening, though urgent workup is unnecessary in asymptomatic patients 9, 5
- Attributing headache directly to sellar findings without considering more common primary headache disorders can lead to misdiagnosis 9, 8
- Missing nonadenomatous lesions is critical, as 18% of visible sellar masses are not adenomas, including Rathke's cleft cysts (19%), craniopharyngiomas (15%), meningiomas (15%), and metastases (5%) 2