What is the management plan for an adult patient with a history of pituitary tumors, surgery, or other endocrine disorders diagnosed with a partially empty sella?

Partially Empty Sella: Definition and Management

What is Partially Empty Sella?

Partially empty sella is a radiological finding where cerebrospinal fluid herniates through the sellar diaphragm into the pituitary fossa, causing variable flattening of the pituitary gland against the sella wall. 1

• Primary empty sella occurs without prior pituitary pathology, surgery, radiation, or pharmacologic treatment and may be associated with idiopathic intracranial hypertension 1
• Secondary empty sella develops after pituitary tumor treatment (surgery, medication, radiation), spontaneous tumor necrosis, pituitary apoplexy, infectious processes, autoimmune disease, or head trauma 1, 2
• The condition is common, occurring in approximately 12% of neuroimaging studies and up to 35% in clinical practice 3

Management Algorithm for Patients with History of Pituitary Tumors or Endocrine Disorders

Initial Assessment: Determine Urgency

Urgent workup is NOT necessary when partially empty sella is an incidental finding in patients without symptoms of pituitary dysfunction or visual changes. 4

However, immediate evaluation is required if:

• Sudden severe headache with oculomotor palsies (suggests pituitary apoplexy) 5
• Acute visual changes or papilledema (indicates increased intracranial pressure) 5
• Signs of acute adrenal crisis (hypotension, altered mental status, severe weakness) 6

Step 1: Confirm Diagnosis with Appropriate Imaging

MRI using high-resolution pituitary protocols is the gold standard for characterizing empty sella and can confirm the diagnosis even without IV contrast. 7, 4

• Thin-section sequences with focused field-of-view targeted for sellar and parasellar assessment are essential 7
• IV contrast is reserved for operative planning and should not be considered first-line 7
• No additional urgent imaging is needed if MRI already confirms partially empty sella without concerning features 4

Step 2: Comprehensive Hormonal Screening (MANDATORY)

All patients with partially empty sella require comprehensive hormonal evaluation regardless of symptoms, as 19-40% demonstrate at least one hormone deficiency. 3, 4

Order the following baseline tests:

• Thyroid axis: TSH and free T4 (deficiency in 8-81% of cases) 5
• Adrenal axis: Early morning (8 AM) cortisol and ACTH (deficiency in 17-62% of cases) 5, 4
• Gonadal axis: Testosterone (males), estradiol (females), FSH, and LH (deficiency in 36-96% of cases) 5, 4
• Growth hormone axis: IGF-1 (deficiency in 61-100% of cases) 5
• Prolactin: To rule out hypersecretion (elevated in approximately 28% of cases) 4, 6

Step 3: Interpret Results and Recognize Central Deficiencies

Central hormone deficiencies present differently than primary gland failure:

• Central hypothyroidism: Low free T4 with low or normal TSH (NOT elevated) 6
• Central adrenal insufficiency: Low cortisol with low or normal ACTH 6
• Hypogonadotropic hypogonadism: Low testosterone/estradiol with low or normal FSH and LH 6

Critical management pitfall: If both adrenal insufficiency and hypothyroidism are present, always start glucocorticoid replacement BEFORE thyroid hormone replacement to avoid precipitating adrenal crisis 6

Step 4: Dynamic Testing When Indicated

Perform 1 mcg cosyntropin stimulation test when baseline morning cortisol is equivocal (typically 3-15 mcg/dL). 6

• Must be performed BEFORE starting steroid replacement 6
• Peak cortisol <18-20 mcg/dL at 30 or 60 minutes confirms adrenal insufficiency 6

Step 5: Ophthalmologic Evaluation

Formal visual field testing and ophthalmology referral are indicated if:

• Any visual symptoms are present 4
• Concerns about increased intracranial pressure exist 4
• Optic chiasm compression is noted on imaging 4
• The patient has a history of pituitary macroadenoma (even if resolved) 8

Visual field defects occur in approximately 34% of symptomatic patients with empty sella 2

Step 6: Endocrinology Referral

Refer to endocrinology if:

• Any hormonal abnormalities are detected on screening 4
• Symptoms suggestive of pituitary dysfunction exist (fatigue, cold intolerance, sexual dysfunction, amenorrhea) 4
• The patient has a history of pituitary tumors requiring ongoing surveillance 6
• Three or more pituitary hormone deficiencies are present (indicates high likelihood of growth hormone deficiency) 6

Step 7: Follow-Up Monitoring

For patients with normal initial hormonal evaluation:

• Careful reassessment at 24-36 months is recommended given the low but present risk of progression 3
• Earlier follow-up if new symptoms develop 3

For patients on hormone replacement:

• TSH and free T4 monitoring as clinically indicated 6
• Morning ACTH and cortisol: monthly for 6 months, then every 3 months for 6 months, then every 6 months for 1 year 6

Common Pitfalls to Avoid

Do not attribute headache directly to empty sella without considering more common primary headache disorders. 4, 5 Empty sella is often an incidental finding unrelated to headache symptoms.

Do not dismiss empty sella findings without hormonal screening. 5 Approximately 30% of patients demonstrate some degree of hypopituitarism upon testing, though most remain asymptomatic 4

Do not order unnecessary urgent tests that won't change immediate management in asymptomatic patients. 4

Do not miss rare but important hormonal deficiencies by failing to perform appropriate comprehensive screening. 4 The most commonly affected axis is growth hormone (61-100%), but all axes require evaluation 5

Do not start thyroid hormone replacement before glucocorticoid replacement in patients with both deficiencies. 6 This can precipitate life-threatening adrenal crisis.

Special Considerations for Patients with Prior Pituitary Tumors

Secondary empty sella following tumor treatment or spontaneous tumor involution is associated with higher rates of hypopituitarism. 1, 8

• Diabetes insipidus is uncommon in nonfunctioning adenomas (only 7% at presentation) but should be assessed if polyuria/polydipsia develops 5
• Some cases of empty sella may result from partial pituitary apoplexy or autoimmune processes 2
• Patients with prior macroadenomas require particularly careful visual monitoring as tumor involution can be associated with visual field defects 8, 9